diff --git a/.idea/AndroidProjectSystem.xml b/.idea/AndroidProjectSystem.xml new file mode 100644 index 0000000..4a53bee --- /dev/null +++ b/.idea/AndroidProjectSystem.xml @@ -0,0 +1,6 @@ + + + + + \ No newline at end of file diff --git a/.idea/appInsightsSettings.xml b/.idea/appInsightsSettings.xml index 3cb5984..1d441c1 100644 --- a/.idea/appInsightsSettings.xml +++ b/.idea/appInsightsSettings.xml @@ -3,6 +3,20 @@ + diff --git a/.idea/render.experimental.xml b/.idea/render.experimental.xml new file mode 100644 index 0000000..8ec256a --- /dev/null +++ b/.idea/render.experimental.xml @@ -0,0 +1,6 @@ + + + + + \ No newline at end of file diff --git a/.idea/runConfigurations.xml b/.idea/runConfigurations.xml new file mode 100644 index 0000000..16660f1 --- /dev/null +++ b/.idea/runConfigurations.xml @@ -0,0 +1,17 @@ + + + + + + \ No newline at end of file diff --git a/app/build.gradle b/app/build.gradle index 75bd145..72fe2ab 100644 --- a/app/build.gradle +++ b/app/build.gradle @@ -11,16 +11,21 @@ plugins { } android { - compileSdk 34 + compileSdk 36 defaultConfig { applicationId "org.apphatchery.gatbreferenceguide" minSdk 24 - targetSdk 34 + targetSdk 36 versionCode 34 versionName "1.13" testInstrumentationRunner "androidx.test.runner.AndroidJUnitRunner" + + // 16KB page size support + ndk { + abiFilters 'arm64-v8a', 'x86_64' + } } buildFeatures { @@ -35,105 +40,118 @@ android { } } compileOptions { - sourceCompatibility JavaVersion.VERSION_1_8 - targetCompatibility JavaVersion.VERSION_1_8 + sourceCompatibility JavaVersion.VERSION_17 + targetCompatibility JavaVersion.VERSION_17 } kotlinOptions { - jvmTarget = '1.8' + jvmTarget = "17" } namespace 'org.apphatchery.gatbreferenceguide' + buildToolsVersion '36.0.0' + ndkVersion '28.2.13676358' } +// 16KB page size configuration +//configurations.configureEach { + //resolutionStrategy { + // Force compatible versions for 16KB page size + //force 'androidx.core:core:1.15.0+' + // force 'androidx.appcompat:appcompat:1.8.0+' + // } +//} + dependencies { - implementation 'androidx.core:core-ktx:1.13.1' - implementation 'androidx.appcompat:appcompat:1.7.0' - implementation 'com.google.android.material:material:1.12.0' - implementation 'androidx.constraintlayout:constraintlayout:2.1.4' + // Core AndroidX libraries + implementation 'androidx.core:core-ktx:1.17.0' + implementation 'androidx.appcompat:appcompat:1.7.1' + implementation 'com.google.android.material:material:1.13.0' + implementation 'androidx.constraintlayout:constraintlayout:2.2.1' implementation 'androidx.preference:preference-ktx:1.2.1' implementation 'com.google.ai.client.generativeai:generativeai:0.9.0' + implementation 'com.google.firebase:firebase-crashlytics-buildtools:3.0.6' testImplementation 'junit:junit:4.13.2' - androidTestImplementation 'androidx.test.ext:junit:1.2.1' - androidTestImplementation 'androidx.test.espresso:espresso-core:3.6.1' + androidTestImplementation 'androidx.test.ext:junit:1.3.0' + androidTestImplementation 'androidx.test.espresso:espresso-core:3.7.0' //BOM // Firebase implementation 'com.google.firebase:firebase-core:21.1.1' implementation 'com.google.firebase:firebase-database-ktx:21.0.0' - implementation 'com.google.firebase:firebase-crashlytics:19.0.2' - implementation 'com.google.firebase:firebase-analytics:22.1.2' + implementation 'com.google.firebase:firebase-crashlytics:20.0.3' + implementation 'com.google.firebase:firebase-analytics:23.0.0' implementation 'com.google.firebase:firebase-dynamic-links-ktx:22.1.0' - implementation 'com.google.firebase:firebase-storage:21.0.0' - implementation("com.google.firebase:firebase-config:22.0.1") + implementation 'com.google.firebase:firebase-storage:22.0.1' + implementation("com.google.firebase:firebase-config:23.0.1") //implementation 'com.google.firebase:firebase-config-ktx:23.0.0' // Retrofit + GSON - implementation "com.squareup.retrofit2:retrofit:2.9.0" - implementation "com.squareup.retrofit2:converter-gson:2.9.0" - implementation("com.squareup.retrofit2:converter-scalars:2.9.0") - implementation 'com.squareup.okhttp3:logging-interceptor:4.9.0' + implementation "com.squareup.retrofit2:retrofit:3.0.0" + implementation "com.squareup.retrofit2:converter-gson:3.0.0" + implementation("com.squareup.retrofit2:converter-scalars:3.0.0") + implementation 'com.squareup.okhttp3:logging-interceptor:5.2.1' // Glide - implementation "com.github.bumptech.glide:glide:4.14.2" + implementation "com.github.bumptech.glide:glide:5.0.5" // Dagger Hilt - implementation 'com.google.dagger:hilt-android:2.51.1' - kapt 'com.google.dagger:hilt-android-compiler:2.51.1' - kapt "androidx.hilt:hilt-compiler:1.2.0" + implementation 'com.google.dagger:hilt-android:2.57.2' + kapt 'com.google.dagger:hilt-android-compiler:2.57.2' + kapt "androidx.hilt:hilt-compiler:1.3.0" // Pendo implementation group:'sdk.pendo.io' , name:'pendoIO', version:'3.3.0.6597', changing:true // Coroutines - implementation 'org.jetbrains.kotlinx:kotlinx-coroutines-core:1.6.4' + implementation 'org.jetbrains.kotlinx:kotlinx-coroutines-core:1.10.2' // Retrofit + GSON - implementation "com.squareup.retrofit2:retrofit:2.9.0" - implementation "com.squareup.retrofit2:converter-gson:2.9.0" + implementation "com.squareup.retrofit2:retrofit:3.0.0" + implementation "com.squareup.retrofit2:converter-gson:3.0.0" // Room - implementation "androidx.room:room-runtime:2.6.1" - kapt "androidx.room:room-compiler:2.6.1" - implementation "androidx.room:room-ktx:2.6.1" + implementation "androidx.room:room-runtime:2.8.2" + kapt "androidx.room:room-compiler:2.8.2" + implementation "androidx.room:room-ktx:2.8.2" // LiveData - implementation "androidx.lifecycle:lifecycle-livedata-ktx:2.8.3" + implementation "androidx.lifecycle:lifecycle-livedata-ktx:2.9.4" // Fragment - implementation 'androidx.fragment:fragment-ktx:1.8.1' + implementation 'androidx.fragment:fragment-ktx:1.8.9' // Navigation components - implementation "androidx.navigation:navigation-fragment-ktx:2.7.7" - implementation "androidx.navigation:navigation-ui-ktx:2.7.7" + implementation "androidx.navigation:navigation-fragment-ktx:2.9.5" + implementation "androidx.navigation:navigation-ui-ktx:2.9.5" // Architectural Components - implementation "androidx.lifecycle:lifecycle-viewmodel-ktx:2.8.3" + implementation "androidx.lifecycle:lifecycle-viewmodel-ktx:2.9.4" // Coroutines - implementation 'org.jetbrains.kotlinx:kotlinx-coroutines-core:1.6.4' - implementation 'org.jetbrains.kotlinx:kotlinx-coroutines-android:1.7.3' + implementation 'org.jetbrains.kotlinx:kotlinx-coroutines-core:1.10.2' + implementation 'org.jetbrains.kotlinx:kotlinx-coroutines-android:1.10.2' // Coroutine Lifecycle Scopes - implementation "androidx.lifecycle:lifecycle-runtime-ktx:2.8.3" + implementation "androidx.lifecycle:lifecycle-runtime-ktx:2.9.4" // Lifecycle implementation "androidx.lifecycle:lifecycle-extensions:2.2.0" // Activity KTX for viewModels() - implementation "androidx.activity:activity-ktx:1.9.0" + implementation "androidx.activity:activity-ktx:1.11.0" //DataStore - implementation "androidx.datastore:datastore-preferences:1.1.1" + implementation "androidx.datastore:datastore-preferences:1.1.7" //Gson - implementation 'com.google.code.gson:gson:2.10.1' + implementation 'com.google.code.gson:gson:2.13.2' - implementation 'org.jsoup:jsoup:1.15.4' + implementation 'org.jsoup:jsoup:1.21.2' //RecyclerViewSwipeDecorator /*A simple utility class to add a background, an icon and a label to a RecyclerView item while swiping it left or right.*/ implementation 'it.xabaras.android:recyclerview-swipedecorator:1.4' - implementation 'androidx.webkit:webkit:1.11.0' + implementation 'androidx.webkit:webkit:1.14.0' } \ No newline at end of file diff --git a/app/src/main/assets/assets/Chevron.png b/app/src/main/assets/assets/Chevron.png new file mode 100644 index 0000000..2a9bfba Binary files /dev/null and b/app/src/main/assets/assets/Chevron.png differ diff --git a/app/src/main/assets/assets/c_lab_diagnosis_image_1.png b/app/src/main/assets/assets/c_lab_diagnosis_image_1.png new file mode 100644 index 0000000..27d02c5 Binary files /dev/null and b/app/src/main/assets/assets/c_lab_diagnosis_image_1.png differ diff --git a/app/src/main/assets/assets/chapter_1_image_1.png b/app/src/main/assets/assets/chapter_1_image_1.png new file mode 100644 index 0000000..681fa78 Binary files /dev/null and b/app/src/main/assets/assets/chapter_1_image_1.png differ diff --git a/app/src/main/assets/assets/chapter_1_image_2.png b/app/src/main/assets/assets/chapter_1_image_2.png new file mode 100644 index 0000000..dec218a Binary files /dev/null and b/app/src/main/assets/assets/chapter_1_image_2.png differ diff --git a/app/src/main/assets/assets/chapter_1_image_3.png b/app/src/main/assets/assets/chapter_1_image_3.png new file mode 100644 index 0000000..ec45332 Binary files /dev/null and b/app/src/main/assets/assets/chapter_1_image_3.png differ diff --git a/app/src/main/assets/assets/chapter_1_image_4.png b/app/src/main/assets/assets/chapter_1_image_4.png new file mode 100644 index 0000000..b02070c Binary files /dev/null and b/app/src/main/assets/assets/chapter_1_image_4.png differ diff --git a/app/src/main/assets/assets/considerations_image_1.png b/app/src/main/assets/assets/considerations_image_1.png new file mode 100644 index 0000000..3584f4a Binary files /dev/null and b/app/src/main/assets/assets/considerations_image_1.png differ diff --git a/app/src/main/assets/assets/ic_chapter.svg b/app/src/main/assets/assets/ic_chapter.svg new file mode 100644 index 0000000..338eedd --- /dev/null +++ b/app/src/main/assets/assets/ic_chapter.svg @@ -0,0 +1,4 @@ + + + + diff --git a/app/src/main/assets/assets/ic_title_icon.SVG b/app/src/main/assets/assets/ic_title_icon.SVG new file mode 100644 index 0000000..c16364e --- /dev/null +++ b/app/src/main/assets/assets/ic_title_icon.SVG @@ -0,0 +1,9 @@ + + + + + + + + + diff --git a/app/src/main/assets/assets/image_1.png b/app/src/main/assets/assets/image_1.png new file mode 100644 index 0000000..42eff84 Binary files /dev/null and b/app/src/main/assets/assets/image_1.png differ diff --git a/app/src/main/assets/assets/image_2.png b/app/src/main/assets/assets/image_2.png new file mode 100644 index 0000000..58b20d3 Binary files /dev/null and b/app/src/main/assets/assets/image_2.png differ diff --git a/app/src/main/assets/assets/image_3.png b/app/src/main/assets/assets/image_3.png new file mode 100644 index 0000000..e6cdac7 Binary files /dev/null and b/app/src/main/assets/assets/image_3.png differ diff --git a/app/src/main/assets/assets/main.js b/app/src/main/assets/assets/main.js new file mode 100644 index 0000000..0c499a6 --- /dev/null +++ b/app/src/main/assets/assets/main.js @@ -0,0 +1,77 @@ +// function to handle tab switching for any table +function activateTab(tableContainer, tabIndex) { + if (!tableContainer) return; + + tableContainer.querySelectorAll('.tab-button, .tab, .tab, .tab').forEach(tab => { + tab.classList.remove('active-option', 'active-tab'); + }); + + tableContainer.querySelectorAll('.option-content, .tab-content, .tab-content, .tab-content').forEach(content => { + content.classList.remove('active-option', 'active-tab'); + }); + + // Add active class to selected tab and content + const selectedTab = tableContainer.querySelectorAll('.tab-button, .tab, .tab, .tab')[tabIndex]; + const selectedContent = tableContainer.querySelectorAll('.option-content, .tab-content, .tab-content, .tab-content')[tabIndex]; + + if (selectedTab) { + if (selectedTab.classList.contains('tab')) { + selectedTab.classList.add('active-tab'); + } else if (selectedTab.classList.contains('tab-button')) { + selectedTab.classList.add('active-option'); + } else if (selectedTab.classList.contains('tab')) { + selectedTab.classList.add('active-tab'); + } else if (selectedTab.classList.contains('tab')) { + selectedTab.classList.add('active-tab'); + } + } + + if (selectedContent) { + if (selectedContent.classList.contains('tab-content')) { + selectedContent.classList.add('active-tab'); + } else if (selectedContent.classList.contains('option-content')) { + selectedContent.classList.add('active-option'); + } else if (selectedContent.classList.contains('tab-content')) { + selectedContent.classList.add('active-tab'); + } else if (selectedContent.classList.contains('tab-content')) { + selectedContent.classList.add('active-tab'); + } + } +} + +// Function to handle tab switching with event +function handleTabSwitch(event, tabIndex) { + // Get the clicked button from the event + const clickedButton = event.currentTarget; + + const tableContainer = clickedButton.closest('.uk-overflow-auto'); + if (!tableContainer) return; + + // Get all tab buttons in this container + const tabButtons = tableContainer.querySelectorAll('.tab-button, .tab, .tab, .tab'); + + // Find the index of the clicked button within its container + const clickedIndex = Array.from(tabButtons).indexOf(clickedButton); + + // Generate a unique ID for the container if it doesn't have one + if (!tableContainer.id) { + tableContainer.id = 'table-' + Math.random().toString(36).substr(2, 9); + } + + // Switch to the correct tab + activateTab(tableContainer, clickedIndex); +} + +function switchTab(tabIndex, event) { + handleTabSwitch(event, tabIndex); +} + +// For Dropdown Togglers +function toggleItem(clickedTitle) { + const itemContent = clickedTitle.nextElementSibling; + + itemContent.classList.toggle('active'); + + const chevronUp = clickedTitle.querySelector('.chevron-up'); + chevronUp.classList.toggle('active'); +} \ No newline at end of file diff --git a/app/src/main/assets/assets/selected_diagnosis_image_1.png b/app/src/main/assets/assets/selected_diagnosis_image_1.png new file mode 100644 index 0000000..a2a20d0 Binary files /dev/null and b/app/src/main/assets/assets/selected_diagnosis_image_1.png differ diff --git a/app/src/main/assets/assets/style.css b/app/src/main/assets/assets/style.css index 07298c8..9887946 100644 --- a/app/src/main/assets/assets/style.css +++ b/app/src/main/assets/assets/style.css @@ -1,30 +1,139 @@ /* Import from the UIkit.css file */ :root { color-scheme: light dark; - --background-color: #fff; - --body-color: #666; - --link-color: #ba6233; - --table-title-color: #8c352d; + --primary-color: #5182FF; + --white-color: #FFFFFF; + --yellow-color: #FFC107; + --green-color: #009C8E; + --background-color: #F7F7F7; + --background-color-secondary: var(--white-color); + --body-color: #747474; + --body-color-secondary: #000; + --link-color: var(--primary-color); + --table-title-color: var(--primary-color); --titles-color: #333; + --inactive-tab-color: var(--white-color); + --inactive-tab-text-color: var(--body-color-secondary); + --active-tab-color: var(--primary-color); + --active-tab-text-color: var(--white-color); + --tab-radius: 5px; + --tab-box-shadow: 0px 0px 32px 0px rgba(187, 187, 187, 0.25); + --transition-duration: 500ms; + --list-title-color: var(--yellow-color); + --divider-color: #C6C6C8; + --last-updated-color: #636366; } @media screen and (prefers-color-scheme: dark) { :root { - --background-color: #202025; - --body-color: #fff; - --link-color: #f3a479; - --table-title-color: #d7958f; - --titles-color: #fff; - /* --title-color: #ff8080; - --subhead-color: #80ff80; - --link-color: #93d5ff; */ + --primary-color: #7090FD; + --white-color: #FFFFFF; + --yellow-color: #FFC107; + --green-color: #009C8E; + --background-color: #2A2A2A; + --background-color-secondary: #343434; + --body-color: #D5D5D5; + --body-color-secondary: #F9F9F9; + --link-color: var(--primary-color); + --table-title-color: var(--primary-color); + --titles-color: var(--white-color); + --inactive-tab-color: var(--background-color-secondary); + --inactive-tab-text-color: #ECECEC; + --active-tab-color: var(--primary-color); + --active-tab-text-color: #F9F9F9; + --tab-radius: 5px; + --tab-box-shadow: 0px 0px 32px 0px rgba(0, 0, 0, 0.2); + --transition-duration: 500ms; + --list-title-color: var(--yellow-color); + --divider-color: #C6C6C8; + --last-updated-color: #B9B9B9; + } +} + +/* Keyframes + Animations */ +@keyframes fadeIn { + from { + opacity: 0; + } + to { + opacity: 1; + } +} + +@keyframes slideInTop { + from { + opacity: 0; + /* height: 0; */ + transform: translateY(-100%); + } + to { + opacity: 1; + /* height: auto; */ + transform: translateY(0); + } +} + +@keyframes slideOutTop { + from { + opacity: 1; + height: auto; + transform: translateY(0); + } + to { + opacity: 0; + height: 0; + transform: translateY(-20%); + } +} + +@keyframes slideInLeft { + from { + opacity: 0; + transform: translateX(-10%); + } + to { + opacity: 1; + transform: translateX(0); + } +} + +@keyframes slideOutRight { + from { + opacity: 1; + transform: translateX(0); + } + to { + opacity: 0; + transform: translateX(-10%); + } +} + +@keyframes slideInBottom { + from { + opacity: 0; + transform: translateY(10%); + } + to { + opacity: 1; + transform: translateY(0); + } +} + +@keyframes slideOutBottom { + from { + opacity: 1; + transform: translateY(0); + } + to { + opacity: 0; + transform: translateY(-10%); } } html { /* 1 */ font-family: -apple-system, BlinkMacSystemFont, "Segoe UI", Roboto, "Helvetica Neue", Arial, "Noto Sans", sans-serif, "Apple Color Emoji", "Segoe UI Emoji", "Segoe UI Symbol", "Noto Color Emoji"; - font-size: 16px; + font-size: 1rem; font-weight: normal; line-height: 1.5; /* 2 */ @@ -36,6 +145,9 @@ html { body { margin: 0; + line-height: 1.7; + padding-top: 2rem; + padding-bottom: 2rem; } a:active, @@ -48,6 +160,9 @@ a, color: #1e87f0; text-decoration: none; cursor: pointer; + word-wrap: break-word; + overflow-wrap: anywhere; + white-space: normal; } a:hover, .uk-link:hover, @@ -66,6 +181,78 @@ strong { font-weight: bolder; } +/* Headings */ +h1, h2, h3, h4, h5, h6 { + color: var(--titles-color); +} + +ul { + list-style: disc; + font-style: normal !important; +} + +img { + height: 100%; + width: 100%; + object-fit: contain; +} + +.ic_chapter_icon { + height: 24px !important; + width: 24px !important; + object-fit: fill !important; +} + +.ic_title_icon { + height: 50px !important; + width: 50px !important; + object-fit: fill !important; +} + +.chapter-header { + display: inline-flex; + flex-direction: column; + justify-content: start; + align-items: start; + margin: 0; + padding: 0; +} + +.chapter-header .header-title .chapter-title { + font-size: 16px; + padding: 0; + margin: 0; +} + +.header-title { + display: flex; + gap: 10px; + align-items: start; + justify-content: start; + margin-bottom: 16px; +} + +.last-updated { + color: var(--last-updated-color); + font-size: 15px; + text-align: start; + font-style: italic; + font-weight: 300; + line-height: 16px; + letter-spacing: -0.408px; + margin-top: 0; + padding-bottom: 16px; +} + +hr { + border-color: var(--divider-color) !important; + border-left: none !important; + border-right: none !important; + border-bottom: none !important; + margin: 0 !important; + padding: 16px 0 !important; +} + /* ======================================================================== Component: Table ========================================================================== */ @@ -81,11 +268,12 @@ strong { /* 2 */ width: 100%; /* 3 */ - margin-bottom: 20px; + margin-bottom: 1.25rem; + background-color: var(--background-color-secondary); } /* Add margin if adjacent element */ * + .uk-table { - margin-top: 20px; + margin-top: 1.25rem; } /* Header cell ========================================================================== */ @@ -93,7 +281,7 @@ strong { * 1. Style */ .uk-table th { - padding: 16px 12px; + padding: 1rem 0.75rem; text-align: left; vertical-align: bottom; /* 1 */ @@ -105,7 +293,7 @@ strong { /* Cell ========================================================================== */ .uk-table td { - padding: 16px 12px; + padding: 1rem 0.75rem; vertical-align: top; } /* @@ -171,11 +359,11 @@ strong { ========================================================================== */ .uk-table-small th, .uk-table-small td { - padding: 10px 12px; + padding: 0.625rem 0.75rem; } .uk-table-large th, .uk-table-large td { - padding: 22px 12px; + padding: 1.375rem 0.75rem; } /* Justify modifier ========================================================================== */ @@ -193,7 +381,7 @@ strong { width: 1px; } .uk-table-expand { - min-width: 150px; + min-width: 9.375rem; } /* Cell link modifier ========================================================================== */ @@ -205,10 +393,10 @@ strong { } .uk-table-link > a { display: block; - padding: 16px 12px; + padding: 1rem 0.75rem; } .uk-table-small .uk-table-link > a { - padding: 10px 12px; + padding: 0.625rem 0.75rem; } /* Responsive table ========================================================================== */ @@ -247,6 +435,10 @@ strong { padding-left: 0; padding-right: 0; } + + .uk-tabs-container .tabs { + justify-content: center !important; /* Center tabs on small screens */ + } } .uk-table tbody tr { transition: background-color 0.1s linear; @@ -317,17 +509,226 @@ table, td, th { } a { - font-style: italic; - text-decoration: none !important; + font-style: normal; + text-decoration: underline !important; color: var(--link-color) !important; } .uk-table th { - padding: 16px 12px; + padding: 1rem 0.75rem; text-align: left; vertical-align: bottom; font-size: 1rem; font-weight: bold; - color: #ba6233; + color: var(--table-title-color); + text-transform: none; +} + +.uk-table td { + color: var(--body-color-secondary); +} + + +/* Tabs */ + +.uk-tabs-container .tabs { + display: flex; + flex-direction: row; + justify-content: center; + flex-wrap: wrap; + align-items: stretch; + align-content: start; + gap: 24px; + width: 100%; + list-style: none; + padding: 0; + margin: 0; +} + +.tab, +.tab-button { + display: inline-flex; + justify-items: center; + justify-content: center; + align-items: center; + gap: 1rem; + padding: 0.75rem; + text-align: center; + vertical-align: bottom; + font-size: 0.870rem; + background-color: var(--inactive-tab-color); + color: var(--inactive-tab-text-color); text-transform: capitalize; + cursor: pointer; + border: none; + border-radius: var(--tab-radius); + box-shadow: var(--tab-box-shadow); + min-width: 120px; + max-width: 200px; + width: auto; + height: auto; + white-space: normal; + word-wrap: break-word; + min-height: 70px; + box-sizing: border-box; +} + +.tab.active-tab, +.tab-button.active-option, +.option.active-option { + background-color: var(--active-tab-color); + color: var(--active-tab-text-color); + box-shadow: var(--tab-box-shadow); +} + +.tab-content, +.option-content { + display: none; + border: none; + width: 100%; + border-collapse: collapse; + border-spacing: 0; + margin: 0; + margin-top: 32px; + padding: 0; + opacity: 0; +} + +.tab-content.active-tab, +.option-content.active-option { + display: table; + opacity: 1; +} + +.highlight { + color: var(--active-tab-color); +} + +th, td { + vertical-align: middle !important; +} + +td { + animation: slideInBottom var(--transition-duration) ease-in-out forwards; +} + +td ul { + padding-left: 1.25rem; + padding-top: 0.625rem; + padding-bottom: 0.625rem; +} + +h3.highlight { + margin-top: 1rem; + padding-top: 0; +} + +.view-in-chapter-highlight { + color: var(--body-color-secondary); +} + +.duration { + font-size: 1rem; + margin-bottom: 0; + padding-bottom: 0; +} + +.nested-list { + list-style: none; + padding-left: 0; +} + +.th-no-highlight { + color: var(--body-color-secondary) !important; + font-weight: 400 !important; +} + +.uk-list { + padding-left: 1.5rem; + font-style: normal; +} + +.uk-list.togglers-list { + padding-left: 0; +} + +.uk-paragraph { + position: relative; + text-indent: 1em; + margin: 1rem 0; +} + +.uk-paragraph::before { + content: ""; + position: absolute; + left: 0; + top: -0.25rem; + height: 2rem; + width: 0.5rem; + background-color: var(--primary-color); + border-radius: 0.25rem; +} + +.uk-list-title, +.uk-table-title, +.custom-table-title { + position: relative; + padding-left: 1.5rem; +} + +.uk-list-title::before, +.uk-table-title::before, +.custom-table-title::before { + content: ""; + position: absolute; + left: 0; + top: -0.1875rem; + height: 2rem; + width: 0.5rem; + border-radius: 0.25rem; } + +.uk-list-title::before { + top: -0.125rem; + background-color: var(--list-title-color); +} + +.custom-table-title::before { + background-color: var(--green-color); +} + +/* Togglers */ +.toggle-title { + cursor: pointer; + position: relative; + display: flex; + justify-content: space-between; + align-items: center; + gap: 2rem; + width: 100%; + z-index: 10; + background-color: var(--background-color); + padding: 0.875rem 0; +} + +.chevron-up { + transform: rotate(-180deg); + transition: transform var(--transition-duration) ease-in-out; + font-size: 1.5rem; +} + +.chevron-up.active { + transform: rotate(0); + transition: transform var(--transition-duration) ease-in-out; +} + +.item { + max-height: 0; + overflow: hidden; + transition: max-height 800ms cubic-bezier(0.075, 0.82, 0.165, 1); +} + +.item.active { + max-height: 5000px; + transition: max-height 800ms cubic-bezier(0.4, 0, 1, 1); +} \ No newline at end of file diff --git a/app/src/main/assets/assets/uikit-icons.js b/app/src/main/assets/assets/uikit-icons.js index 4904e1c..1267116 100644 --- a/app/src/main/assets/assets/uikit-icons.js +++ b/app/src/main/assets/assets/uikit-icons.js @@ -31,7 +31,7 @@ "check": "", "chevron-double-left": "", "chevron-double-right": "", - "chevron-down": "", + "chevron-up": "", "chevron-left": "", "chevron-right": "", "chevron-up": "", diff --git a/app/src/main/assets/json/chart.json b/app/src/main/assets/json/chart.json index 280483e..db8bc8f 100644 --- a/app/src/main/assets/json/chart.json +++ b/app/src/main/assets/json/chart.json @@ -112,7 +112,7 @@ "chartHomePosition": 0 }, { - "id": "table_17_what_to_start_choice_of_tb_therapy_and_antiretroviral_therapy_(art)_when)treating_co-infected_patients", + "id": "table_17_what_to_start_choice_of_tb_therapy_and_antiretroviral_therapy_(art)_when_treating_co-infected_patients", "subChapterTitle": "Antiretroviral Therapy (ART) and Treatment of HIV Seropositive Patients with Active Tuberculosis Disease", "subChapterId": 28, "chartTitle": "Table 17: What to start: Choice of TB therapy and Antiretroviral Therapy (ART) when treating co-infected patients", diff --git a/app/src/main/assets/json/subchapter.json b/app/src/main/assets/json/subchapter.json index 38a94c7..20fe290 100644 --- a/app/src/main/assets/json/subchapter.json +++ b/app/src/main/assets/json/subchapter.json @@ -205,194 +205,210 @@ { "subChapterId": 30, "chapterId": 5, - "subChapterTitle": "Treatment of Extrapulmonary TB (Table 19)", + "subChapterTitle": "Treatment of Extrapulmonary TB", "url": "5_treatment_of_current_(active)_disease_therapy__i__treatment_of_extrapulmonary_tb", "lastUpdated": "June 2024" }, + { - "subChapterId": 31, + "subChapterId": 32, "chapterId": 5, - "subChapterTitle": "Adjunctive Use of Corticosteroid Therapy (Table 19)", + "subChapterTitle": "Adjunctive Use of Corticosteroid Therapy", "url": "5_treatment_of_current_(active)_disease_therapy__j__adjunctive_use_of_corticosteroid_therapy", "lastUpdated": "June 2024" }, { - "subChapterId": 31, + "subChapterId": 33, "chapterId": 6, "subChapterTitle": "Introduction", "url": "6_pregnancy_and_tb", "lastUpdated": "June 2024" }, { - "subChapterId": 32, + "subChapterId": 34, "chapterId": 6, "subChapterTitle": "Treatment for LTBI and Risk Factors", "url": "6_pregnancy_and_tb__a__treatment_for_ltbi_and_risk_factors", "lastUpdated": "June 2024" }, { - "subChapterId": 33, + "subChapterId": 35, "chapterId": 6, "subChapterTitle": "Treatment of Active TB in Pregnancy", "url": "6_pregnancy_and_tb__b__treatment_of_active_tb_in_pregnancy", "lastUpdated": "June 2024" }, { - "subChapterId": 34, + "subChapterId": 36, "chapterId": 7, "subChapterTitle": "Children Tuberculosis", "url": "7_childhood_tuberculosis", "lastUpdated": "June 2024" }, { - "subChapterId": 35, + "subChapterId": 37, "chapterId": 7, "subChapterTitle": "Management Considerations", "url": "7_childhood_tuberculosis__a__management_considerations", "lastUpdated": "June 2024" }, { - "subChapterId": 36, + "subChapterId": 38, "chapterId": 8, "subChapterTitle": "Tuberculosis and Long-Term Care Facilities", "url": "8_tuberculosis_and_long_term_care_facilities", "lastUpdated": "June 2024" }, { - "subChapterId": 37, + "subChapterId": 39, "chapterId": 9, "subChapterTitle": "BCG Vaccination", "url": "9_bcg_vaccination", "lastUpdated": "June 2024" }, { - "subChapterId": 38, + "subChapterId": 40, "chapterId": 10, "subChapterTitle": "Introduction", "url": "10_tb_infection_control_hospital_isolation_procedures", "lastUpdated": "June 2024" }, { - "subChapterId": 39, + "subChapterId": 41, "chapterId": 10, "subChapterTitle": "Administrative Controls", "url": "10_tb_infection_control_hospital_isolation_procedures__a__administrative_controls", "lastUpdated": "June 2024" }, { - "subChapterId": 40, + "subChapterId": 42, "chapterId": 10, "subChapterTitle": "Surveillance for Health Care Workers", "url": "10_tb_infection_control_hospital_isolation_procedures__b__surveillance_for_health_care_workers", "lastUpdated": "June 2024" }, { - "subChapterId": 41, + "subChapterId": 43, "chapterId": 10, "subChapterTitle": "Environmental Controls", "url": "10_tb_infection_control_hospital_isolation_procedures__c__environmental_controls", "lastUpdated": "June 2024" }, { - "subChapterId": 42, + "subChapterId": 44, "chapterId": 10, "subChapterTitle": "Personal Respiratory Protection", "url": "10_tb_infection_control_hospital_isolation_procedures__d__personal_respiratory_protection", "lastUpdated": "June 2024" }, { - "subChapterId": 43, + "subChapterId": 45, "chapterId": 11, "subChapterTitle": "Introduction", "url": "11_community_tuberculosis_control", "lastUpdated": "June 2024" }, { - "subChapterId": 44, + "subChapterId": 46, "chapterId": 11, "subChapterTitle": "TB Surveillance in Georgia", "url": "11_community_tuberculosis_control__a__tb_surveillance_in_georgia", "lastUpdated": "June 2024" }, { - "subChapterId": 45, + "subChapterId": 47, + "chapterId": 11, + "subChapterTitle": "How to Report TB as a Notifiable Disease", + "url": "11_community_tuberculosis_control__b__how_to_report_tb_as_a_notifiable_disease", + "lastUpdated": "June 2024" + }, + { + "subChapterId": 48, "chapterId": 11, "subChapterTitle": "TB Case Definitions for Public Health Surveillance", - "url": "11_community_tuberculosis_control__b__tb_case_definitions_for_public_health_surveillance", + "url": "11_community_tuberculosis_control__c__tb_case_definitions_for_public_health_surveillance", "lastUpdated": "June 2024" }, { - "subChapterId": 46, + "subChapterId": 49, "chapterId": 11, "subChapterTitle": "Role of the Health Department", - "url": "11_community_tuberculosis_control__c__role_of_the_health_department", + "url": "11_community_tuberculosis_control__d__role_of_the_health_department", "lastUpdated": "June 2024" }, { - "subChapterId": 47, + "subChapterId": 50, "chapterId": 11, "subChapterTitle": "Hospital Discharge Planning for Patients with Suspected or Proven TB", - "url": "11_community_tuberculosis_control__d__hospital_discharge_planning_for_patients_with_suspected_or_proven_tb", + "url": "11_community_tuberculosis_control__e__hospital_discharge_planning_for_patients_with_suspected_or_proven_tb", "lastUpdated": "June 2024" }, { - "subChapterId": 48, + "subChapterId": 51, "chapterId": 11, - "subChapterTitle": "The U.S.-Mexico Binational Tuberculosis Referral Program (CureTB)", - "url": "11_community_tuberculosis_control__e__the_us_mexico_binational_tuberculosis_referral_program_(curetb)", + "subChapterTitle": "Interjurisdictional TB Notification (IJN)", + "url": "11_community_tuberculosis_control__f__interjurisdictional_tb_notification(ijn)", "lastUpdated": "June 2024" }, + { - "subChapterId": 48, + "subChapterId": 53, + "chapterId": 11, + "subChapterTitle": "CureTB Program (International Linkage to TB Care)", + "url": "11_community_tuberculosis_control__g__curetb_program_(internation_linkage_to_tb_care)", + "lastUpdated": "June 2024" + }, + { + "subChapterId": 54, "chapterId": 12, "subChapterTitle": "Alternative Housing Program for Homeless TB Patients in Georgia", "url": "12_alternative_housing_program_for_homeless_tb_patients_in_georgia", "lastUpdated": "June 2024" }, { - "subChapterId": 50, + "subChapterId": 55, "chapterId": 13, "subChapterTitle": "Georgia Department of Public Health (DPH) Community Guidelines for Respiratory Isolation of Patients With Active TB in the Community", "url": "13_georgia_department_of_public_health_(dph)_community_guidelines_for_respiratory", "lastUpdated": "June 2024" }, { - "subChapterId": 51, + "subChapterId": 56, "chapterId": 14, "subChapterTitle": "References", "url": "14_references", "lastUpdated": "June 2024" }, { - "subChapterId": 52, + "subChapterId": 57, "chapterId": 15, "subChapterTitle": "Appendix: District TB Coordinators (by district)", "url": "15_appendix_district_tb_coordinators_(by_district)", "lastUpdated": "June 2024" }, { - "subChapterId": 53, + "subChapterId": 58, "chapterId": 16, "subChapterTitle": "Abbreviations", "url": "16_abbreviations", "lastUpdated": "June 2024" }, { - "subChapterId": 54, + "subChapterId": 59, "chapterId": 17, "subChapterTitle": "Acknowledgements", "url": "17_acknowledgements", "lastUpdated": "June 2024" }, { - "subChapterId": 55, + "subChapterId": 60, "chapterId": 18, "subChapterTitle": "Hello and welcome clinical statement", "url": "18_hello_and_welcome_clinical_statement", "lastUpdated": "June 2024" }, { - "subChapterId": 56, + "subChapterId": 61, "chapterId": 19, "subChapterTitle": "For more information", "url": "19_for_more_information", diff --git a/app/src/main/assets/pages/10_tb_infection_control_hospital_isolation_procedures.html b/app/src/main/assets/pages/10_tb_infection_control_hospital_isolation_procedures.html index 0f701b3..183650b 100644 --- a/app/src/main/assets/pages/10_tb_infection_control_hospital_isolation_procedures.html +++ b/app/src/main/assets/pages/10_tb_infection_control_hospital_isolation_procedures.html @@ -15,11 +15,24 @@
-

+

+
+
+
+ +
+

X. TB Infection Control: Hospital Isolation Procedures

+
+

Last Updated October 2025

+
+
+
+ +

Effective infection control efforts are essential in preventing nosocomial transmission of TB. A hierarchy of control measures is recommended to prevent TB transmission in health care facilities.

-
- - - + diff --git a/app/src/main/assets/pages/16_abbreviations.html b/app/src/main/assets/pages/16_abbreviations.html index a81744e..6972e0c 100644 --- a/app/src/main/assets/pages/16_abbreviations.html +++ b/app/src/main/assets/pages/16_abbreviations.html @@ -15,20 +15,31 @@
+
+
+
+
+ +
+

XVI. Abbreviations

+
+

Last Updated October 2025

+
+
+
AFB : Acid-Fast Bacilli
- AG : Aminoglycoside
AIDS : Acquired Immunodeficiency Syndrome
ALT : Alanine Aminotransferase
ART : Antiretroviral Therapy
AST : Aspartate Aminotransferase
ATS : American Thoracic Society
- BCG : Bacillus Calmette-Guerin
+ BCG : Bacillus Calmette-Guérin
BID : Bis in die (Twice Daily)
CBC : Complete Blood Count
CDC : Centers for Disease Control and Prevention
CNS : Central Nervous System
CXR : Chest X-Ray
- DST : Drug Susceptibility Tests
+ DST : Drug Susceptibility Tests or Drug Susceptibility Testing
DTH : Delayed-type Hypersensitivity
DOPT : Directly Observed Preventive Therapy
DOT : Directly Observed Therapy
diff --git a/app/src/main/assets/pages/16_for_more_information.html b/app/src/main/assets/pages/16_for_more_information.html index 579d204..4517509 100644 --- a/app/src/main/assets/pages/16_for_more_information.html +++ b/app/src/main/assets/pages/16_for_more_information.html @@ -14,7 +14,7 @@
-

FOR MORE INFORMATION

+

XIX. FOR MORE INFORMATION


Emory University School of Medicine Department of Medicine
49 Jesse Hill Jr. Drive, Atlanta, GA 30303
tb@emory.edu

diff --git a/app/src/main/assets/pages/17_acknowledgements.html b/app/src/main/assets/pages/17_acknowledgements.html index bf2b238..eae15c3 100644 --- a/app/src/main/assets/pages/17_acknowledgements.html +++ b/app/src/main/assets/pages/17_acknowledgements.html @@ -15,25 +15,26 @@
+
+
+
+
+ +
+

XVII. Acknowledgements

+
+
+
+

+ The Georgia TB Reference Guide was initially adapted from Tuberculosis at a Glance, A Reference Guide for Practitioners Covering the Basic Elements of Tuberculosis Care, designed and produced by the New York City Department of Health, Bureau of Tuberculosis Control. +

+ +

+ Multiple updates to print copies were subsequently made and in 2022, we transitioned to a mobile app through collaboration with the Georgia CTSA appHatchery. Many thanks to appHatchery members Santiago Arconada Alvarez, Morgan Greenleaf, Jingying Yao, Wilbur Lam, Maxwell Jr Kapezi, Naomi Nyama, Wiza Munthali, Kennedy Linzie, Hope Madziakapita, Kelvin Sande, and Mabuchi Nyirenda. In 2024 and 2025 we have updated and extensively revised the Guide app based on new scientific knowledge and user feedback. +

-

- This booklet has been updated from the previous versions of the - Georgia TB Reference Guide and was initially adapted from - Tuberculosis at a Glance, A Reference Guide for Practitioners - Covering the Basic Elements of Tuberculosis Care, designed and - produced by the New York City Department of Health, Bureau of - Tuberculosis Control. We extend a special thanks to Lisa - Cranmer, MD, MPH, in the Division of Pediatric Infectious - Diseases at Emory University for updating the childhood - tuberculosis section; to Jane Tapia, RN, Alison Hoover, MPH, Alice Daramola, MPH, and - Rakiyah Johnson, MPH, and Lisa Sharling, PhD, for editorial - assistance; to Jessica Lian, PhD, for copy editing; to Jasmine Aqua, - MPH, and Dr. Rose-Marie Sales, former Director, Tuberculosis - Program, Georgia Department of Public Health (DPH) for updates - on TB epidemiology in Georgia and input on public health - components of the Guide; and Benjamin Yarn and Andrea (Lynn) - Latham at the Georgia DPH TB Control Program for their ongoing - support and collaboration. +

+ In addition to the Guide app users who have provided valuable feedback, we extend a special thanks to Andi Shane, MD, MPH, MSc, and Collin Dubick, MD, in the Division of Pediatric Infectious Diseases at Emory University for updating the childhood tuberculosis section; Kyleigh Marshall, MPH for editorial assistance; and to the Georgia Department of Public Health (DPH) TB Program including Benjamin Yarn, Andrea (Lynn) Latham, and Kayleigh Nerhood for their ongoing and unwavering support and collaboration.

diff --git a/app/src/main/assets/pages/18_hello_and_welcome_clinical_statement.html b/app/src/main/assets/pages/18_hello_and_welcome_clinical_statement.html index 49b156a..0c54e4d 100644 --- a/app/src/main/assets/pages/18_hello_and_welcome_clinical_statement.html +++ b/app/src/main/assets/pages/18_hello_and_welcome_clinical_statement.html @@ -17,30 +17,16 @@

Dear Clinician:
- This booklet responds to clinicians’ questions about tuberculosis - infection, disease, and control. The standards and guidelines are - based on the work and experience of the American Thoracic - Society (ATS), the Centers for Disease Control and Prevention - (CDC), the Infectious Disease Society of America (IDSA), Emory - University, the World Health Organization (WHO), and the Atlanta - TB Prevention Coalition. This edition contains updated - recommendations on the treatment of latent tuberculosis infection - (LTBI) and treatment of active tuberculosis disease.

- The treatment of a patient with TB always requires a clinician to - exercise clinical and professional judgment. These guidelines - provide a framework for the treatment of patients with TB - infection or disease. Standardized treatment offers the greatest - opportunity for controlling tuberculosis.

- This is not an exhaustive treatment of the subjects covered. It is an - accessible reference guide. Since guidelines for treating and - controlling TB continue to evolve, it is appropriate for clinicians to - check further for new treatment regimens. + + The Georgia TB Reference Guide responds to clinicians’ questions about tuberculosis infection, disease, and prevention and control. The standards and guidelines are based on the work and recommendations of the American Thoracic Society (ATS), the Centers for Disease Control and Prevention (CDC), the Infectious Disease Society of America (IDSA), Emory University, and the World Health Organization (WHO). The Guide also provides guidance from the Georgia Department of Public Health (DPH) TB Program and contact information for District TB Coordinators. This updated edition of the Guide contains updated recommendations on the treatment of latent TB infection (LTBI) and treatment of active TB disease and an updated format inspired by users of the Guide app. +

+

+ The treatment of a person with TB always requires a clinician to exercise clinical and professional judgment. These guidelines provide a framework for the diagnosis and treatment of persons with TB infection or active TB disease. +

+

This is not an exhaustive review of the subjects covered. It is an accessible reference guide which provides guidance for diagnosis, treatment and prevention of TB. Since guidelines for treating, preventing, and controlling TB continue to evolve, it is appropriate for clinicians to check further for new treatment regimens.

Detailed information is available from:

-
  • Your county public health department and the Georgia - Department of Public Health, Tuberculosis Control Program: - (404) 657-2634 -
    • +
  • Your county public health department and the Georgia Department of Public Health (DPH) TB Program (phone: 404-657-2634 or online: https://dph.georgia.gov/health-topics/tuberculosis-tb-prevention-and-control).

    • Sincerely,

    diff --git a/app/src/main/assets/pages/19_for_more_information.html b/app/src/main/assets/pages/19_for_more_information.html index 9edb4ae..422045d 100644 --- a/app/src/main/assets/pages/19_for_more_information.html +++ b/app/src/main/assets/pages/19_for_more_information.html @@ -14,27 +14,24 @@
    -

    Emory University School of Medicine Department of Medicine
    49 Jesse Hill Jr. Drive, - Atlanta, GA 30303
    tb@emory.edu -
    Georgia Department of Public Health Division of Health Protection
    -

    2 Peachtree Street, NW, Atlanta, GA 30303
    (404) 657-2634
    https://dph.georgia.gov/tuberculosis-tb-prevention-and-control -

    - -
    TB Hotline for Physicians
    -

    1-800-4TB-DOCS (1-800-482-3627)

    - -
    CDC Division of TB Elimination
    -

    http://www.cdc.gov/tb/

    +
    Georgia Department of Public Health Tuberculosis Program Division of Health Protection
    + +

    200 Piedmont Ave SE

    + +

    West Tower Suite-1541F

    + +

    Atlanta, GA 30334

    + +

    (404) 657-2634

    + + https://dph.georgia.gov/tuberculosis-tb-prevention-and-control +
    +
    +

    For additional information on the TB Reference Guide, please visit:

    + https://dph.georgia.gov/health-topics/tuberculosis-tb-prevention-and-control/tb-clinicians-and-healthcare-providers
    -

    For additional copies of this guide, call: (404) 657-2634 or visit: - http://dph.georgia.gov/sites/dph.georgia.gov/files/TB-Pub-GATBReferenceGuide2020.pdf

    -

    -

    Printed by the Emory University School of Medicine through a contract with the Georgia Department of Public - Health


    - image../assets/imageimage
    diff --git a/app/src/main/assets/pages/1_epidemiology.html b/app/src/main/assets/pages/1_epidemiology.html index 93abd88..cda20b5 100644 --- a/app/src/main/assets/pages/1_epidemiology.html +++ b/app/src/main/assets/pages/1_epidemiology.html @@ -14,102 +14,73 @@
    -
      - -
    • Worldwide, TB is an enormous global public health problem. - The World Health Organization (WHO) estimates that there - were about 10 million new cases of TB disease and more than 1.5 million deaths due to TB in 2020. -
      • - -
    • TB remains the leading cause of death due to an infectious disease - globally and prior to the COVID-19 pandemic was the leading cause of death due to a single infectious disease. - TB is the leading cause of death in persons with human - immunodeficiency virus (HIV), acquired immunodeficiency - syndrome (HIV/AIDS) worldwide (although not in the United - States).The COVID-19 pandemic has impacted progress in TB control and prevention globally and - led to increased TB-related mortality. -
      • -
    • Approximately one-fourth of the world’s population is estimated to be infected with and harbors - Mycobacterium - tuberculosis (i.e., have latent TB infection) and therefore is at risk for developing active disease. -
      • - -
    • The interaction between the TB epidemic and the HIV/AIDS - epidemic is lethal. TB adds to the burden of illness of HIV infected people and shortens their life - expectancy, - while the HIV epidemic spurs the spread of TB. -
      • -
    • In the U.S. there was a resurgence of TB from 1985 to 1992. The - number of cases increased 20% during this time period, peaking in - 1992 with 26,673 cases reported. The increased case - numbers were attributed to the HIV epidemic, decreased funding for public health, immigration from countries - where TB is endemic, and transmission of TB in congregate settings such - as hospitals, correctional institutions, and homeless shelters. -
      • - -
    • Due to a number of public health interventions, TB cases began - declining in 1992 in the U.S. From 1992 through 2020, there has - been a 74% decrease in the number of cases, as TB control was - strengthened nationally. In 2020, the U.S. reported 7,174 new - TB cases (2.2 per 100,000 population). The decrease over this time span - is attributed to strengthened public health infrastructure for - TB prevention and control nationwide. However, there was about a - ~20% decrease in reported cases between 2019 and 2020. - The COVID-19 pandemic has probably affected reported TB incidence - in the U.S. in several ways, including a combination of TB - underdiagnosis and a true reduction in incidence. -
      • -
    • TB is not evenly distributed among the U.S. population. Cases - occur disproportionately in urban areas, in conditions of poverty and over-crowding, and among racial and - ethnic - minorities and foreign-born persons. In 2020, ~70% of the U.S. TB - cases occurred among non-US born persons (56.6% in Georgia). -
      • -
    • The average lifetime risk of developing active TB following TB - infection, if no treatment of latent TB infection is received, is - approximately 5-10% (with the greatest risk occurring in the - first two years after infection). UNAIDS estimates that persons - infected with both TB and HIV are 30 to 50 times more likely to - develop TB disease than those infected with TB but who do not - have HIV infection (10% per year risk of progression to active - TB disease among people living with HIV who have LTBI). -
      • -
    • Drug-resistant TB is a major challenge to global TB control and - associated with higher morbidity and mortality compared to - drug-susceptible disease. The treatment of highly drug resistant M. tuberculosis requires longer, - more - complex and expensive treatment regimens. Multidrug-resistant TB (MDRTB) is defined as resistance to at - least - isoniazid (INH) and ri fampin (RIF); extensively drug resistant (XDR)-TB is defined as - MDR-TB plus resistance to a fluoroquinolone (FQN) drug plus - an injectable drug (kanamycin, amikacin, and/or capreomycin). - MDR-TB treatment regimens are complicated with many potential adverse effects and may require up to 24 - months of treatment. -
      • -
    • Every culture-positive TB case for which an isolate is submitted to the state health department is subjected - to whole-genome sequencing (WGS) through CDC. WGS data is used to identify and confirm recent transmission and - supplement contact investigations done by the state and local health departments
      • -
    • The State of Georgia had TB rates higher than the U.S. - average for several decades but rates have decreased in recent years, and currently Georgia has a TB incidence - rate below the U.S. national average. In 2020, Georgia had 212 new TB cases and the incidence in Georgia was less than that for the U.S. - (2.1 TB cases per 100,000 population in Georgia vs. 2.2 cases per 100,000 - population in the U.S.). Of the culture-confirmed TB cases tested for drug susceptibility in Georgia in - 2020, 8.9% - had resistance to INH, and - 1.2% were MDR. -
      • - Number of tb cases city of atlanta metro atlanta georgia 2000-2020 -
      -
      -
      - US-born and Foreign-born TB cases georgia 2000-2020 -
      -
    • More than half of TB cases in Georgia occur in the metropolitan Atlanta area.
      • -
    +
    +
    +
    +
    + +
    +

    I. Epidemiology

    +
    +

    Last Updated October 2025

    +
    +
    +
    +
    + +

    Worldwide, TB is an enormous global public health problem. The World Health Organization (WHO) estimates that there were 10.8 million new cases of active TB disease and more than 1.25 million deaths due to TB in 2023.

    + +

    Tuberculosis (TB) is again the leading cause of death due to an infectious disease globally. TB had been the leading cause of death in 2019 prior to the COVID-19 pandemic. COVID-19 emerged globally as the leading cause of death due to a single infectious disease, but the number of COVID-19 related deaths have decreased, and TB re-emerged as the leading cause of death due to an infectious disease in 2023. TB remains the leading cause of death in persons with Human Immunodeficiency Virus (HIV) infection. +

    + +

    Approximately one-fourth of the world’s population is estimated to be infected with Mycobacterium tuberculosis (i.e., have latent TB infection [LTBI]) and therefore potentially at risk for developing active TB disease.

    + +

    In the U.S., there was a resurgence of TB from 1985 to 1992. The number of cases increased 20% during this time period, peaking in 1992 with 26,673 cases reported. The increased case numbers were attributed to the HIV epidemic, decreased funding for public health, immigration from countries where TB is endemic, and transmission of TB in congregate settings such as hospitals, correctional institutions, and homeless shelters.

    + + + Source: CDC + + + +

    Due to a number of public health interventions, TB cases began declining in 1992 in the U.S. Between 1992 and 2020, there was a 74% decrease in the number of cases, as TB control and prevention was strengthened nationally. The number of TB cases in the U.S. declined considerably in 2020 to 7,171, coinciding with the COVID-19 pandemic. However, TB case counts and incidence rates increased in 2021-2024. +

    + +

    + In 2024, 10,347 TB cases were provisionally reported by CDC in the US with a corresponding rate of 3.0 cases per 100,000 population. In 2023, the CDC reported 9,633 cases of active TB disease in the U.S. and an incidence rate of 2.9 cases per 100,000 persons. The incidence rate in 2022 was2.5 per 100,000). The TB case count in 2024 in the U.S. is the highest reported since 2013, and the incidence rate is the highest since 2016. +

    + + + Source: CDC + +

    TB is not evenly distributed among the U.S. population. Recovery from pandemic-related health care disruptions, increases in post-pandemic travel and migration, and outbreaks in several states have likely contributed to recent TB trends. Cases occur disproportionately in urban areas, in conditions of poverty, undernutrition, over-crowding, and among racial and ethnic minorities and non-US-born persons. +

    +

    + In 2024, 76% of US TB cases occurred among Non-US Born persons. In 2023, 776% of the U.S. TB cases occurred among non-US born persons. +

    + + + + Data on US Born and Non-US Born cases unavailable in the State of Georgia for 2024. +

    + In 2023 in the state of Georgia, 57% of TB cases occurred among non-US born persons in 2023 +

    +

    The average lifetime risk of developing active TB following TB infection, if no treatment of latent TB infection (LTBI) is received, is approximately 5%. The greatest risk of progression to active TB disease is within the first two years following infection with M. tuberculosis. UNAIDS estimates that persons infected with both M. tuberculosis and HIV are 30 to 50 times more likely to develop active TB disease than those infected with M. tuberculosis but who do not have HIV infection. The risk of progression to active TB disease among people living with untreated HIV who have LTBI is up to 10% per year. +

    + +

    Drug-resistant TB is a major challenge to global TB prevention and control efforts and historically associated with a higher morbidity and mortality compared to drug-susceptible disease. Multidrug (MDR) TB is defined as resistance to at least isoniazid (INH) and rifampin (RIF). Extensively drug resistant (XDR)-TB is defined as MDR-TB plus resistance to a fluoroquinolone (FQN) drug and either bedaquiline or levofloxacin. There have been significant improvements (more potent regimens given over shorter periods of time) in the past several years for the treatment of highly drug resistant TB include use of the BPaL (bedaquiline, protamanid, levofloxacin) and BPaLM (BPaL plus moxifloxacin) regimens which require 6-9 months of therapy. +

    + +

    Every culture-positive TB case for which an isolate is submitted to the state health department is subjected to whole-genome sequencing (WGS) through CDC. WGS data is used to identify and confirm recent transmission and supplement contact investigations done by the state and local health departments.

    + +

    The State of Georgia had TB rates higher than the U.S. average for several decades, but rates have decreased significantly over the past decade, and currently Georgia has a TB incidence rate below the U.S. national average. In 2024, Georgia provisionally reported 253 new TB cases, compared to 246 in 2023. In 2023, Georgia had an incidence of 2.2 TB cases per 100,000 population which was below the US TB incidence of 2.9 cases per 100,000. Of the culture-confirmed TB cases tested for drug susceptibility in Georgia in 2023, 7.4% had resistance to INH, and only 2 cases were MDR. +

    + + + More than half of TB cases in Georgia occur in the metropolitan Atlanta area. +
    diff --git a/app/src/main/assets/pages/2_diagnostic_tests_for_latent_tb_infection_(ltbi).html b/app/src/main/assets/pages/2_diagnostic_tests_for_latent_tb_infection_(ltbi).html index 94f63b1..bd8e89d 100644 --- a/app/src/main/assets/pages/2_diagnostic_tests_for_latent_tb_infection_(ltbi).html +++ b/app/src/main/assets/pages/2_diagnostic_tests_for_latent_tb_infection_(ltbi).html @@ -14,15 +14,27 @@
    -

    There is no "gold standard" test for latent TB infection (LTBI). +

    +
    +
    +
    + +
    +

    II. Diagnostic Tests for Latent TB Infection (LTBI)

    +
    +

    Last Updated October 2025

    +
    +
    +
    +

    There is no "gold standard" test for latent TB infection (LTBI). Two types of diagnostic tests to detect LTBI are now available. These include the tuberculin skin test (TST) which has been available for > 100 years and a newer generation of diagnostic tests, the interferon-γ release assays (IGRAs), which are T-cell-based in - vitro blood tests. Two IGRAs are approved for use by the U.S. FDA. Neither the TST nor IGRA tests can distinguish LTBI from active TB disease.

    -

    List of sub chapters

    -
      +

      List of sub chapters

      + -

      List of charts

      -
        +

        List of charts

        +
        • Table 1. Interpretation Criteria for the QuantiFERON-TB Gold Plus Test (QFT-Plus) diff --git a/app/src/main/assets/pages/2_diagnostic_tests_for_latent_tb_infection_(ltbi)__a__tuberculin_skin_test.html b/app/src/main/assets/pages/2_diagnostic_tests_for_latent_tb_infection_(ltbi)__a__tuberculin_skin_test.html index 525be24..9c93ea0 100644 --- a/app/src/main/assets/pages/2_diagnostic_tests_for_latent_tb_infection_(ltbi)__a__tuberculin_skin_test.html +++ b/app/src/main/assets/pages/2_diagnostic_tests_for_latent_tb_infection_(ltbi)__a__tuberculin_skin_test.html @@ -15,8 +15,20 @@
          +
          +
          +
          +
          + +
          +

          II. Diagnostic Tests for Latent TB Infection (LTBI)

          +
          +

          Last Updated October 2025

          +
          +
          +
          -

          The tuberculin skin test (TST) measures a delayed-type hypersensitivity (DTH) reaction (recruitment of +

          The tuberculin skin test (TST) measures a delayed-type hypersensitivity (DTH) reaction (recruitment of memory T cells to the site of an intradermal injection of purified protein derivative [PPD]). The TST should be carried out using the Mantoux method. Multiple puncture tests (Tine and Heaf) should not be used. @@ -28,11 +40,11 @@ discrete, pale elevation of the skin (a wheal) 6 mm to 10 mm in diameter is produced.

          -

          Needles should not be recapped, purposely bent or broken, removed from disposable syringes, or otherwise +

          Needles should not be recapped, purposely bent or broken, removed from disposable syringes, or otherwise manipulated by hand. Dispose of needles and syringes in puncture-resistant containers. Follow standard precautions for infection control.

          -

          +

          TSTs should be read 48 to 72 hours after administration. If test reading is delayed, a positive reaction may still be measurable up to one week after testing. A test cannot be read as negative if @@ -42,7 +54,7 @@ recorded in millimeters. If no induration is present, record “0 mm.” Do not measure erythema (redness).

          -

          Limitations of the TST include cross reactions between TST and +

          Limitations of the TST include cross reactions between TST and Bacillus Calmette-Guerin (BCG) and non-tuberculous mycobacteria. Tuberculin skin testing is not contraindicated for persons who have been vaccinated with BCG, but an advantage of the diff --git a/app/src/main/assets/pages/2_diagnostic_tests_for_latent_tb_infection_(ltbi)__b__criteria_for_a_positive_tuberculin_test_by_risk_group.html b/app/src/main/assets/pages/2_diagnostic_tests_for_latent_tb_infection_(ltbi)__b__criteria_for_a_positive_tuberculin_test_by_risk_group.html index fb9982b..34b38f6 100644 --- a/app/src/main/assets/pages/2_diagnostic_tests_for_latent_tb_infection_(ltbi)__b__criteria_for_a_positive_tuberculin_test_by_risk_group.html +++ b/app/src/main/assets/pages/2_diagnostic_tests_for_latent_tb_infection_(ltbi)__b__criteria_for_a_positive_tuberculin_test_by_risk_group.html @@ -14,19 +14,35 @@

          +
          +
          +
          +
          + +
          +

          II. Diagnostic Tests for Latent TB Infection (LTBI)

          +
          +

          Last Updated October 2025

          +
          +
          +
          -

          Reaction ≥ 5 mm of induration

          -
            -
          • Persons living with Human Immunodeficiency Virus (HIV)
            • -
          • Recent contact with an infectious TB case
            • -
          • Fibrous changes on chest radiograph consistent with prior TB
            • -
          • Patients with organ transplants and other immunosuppressed patients (receiving the equivalent of > 15 - mg/d of - prednisone for 1 month or more including patients who will - receive TNF-α inhibitors) -
            • -
          -

          Reaction ≥ 10 mm of induration

          +
          + Reaction ≥ 5 mm of induration⌃ +
          +
            +
          • Persons living with Human Immunodeficiency Virus (HIV)
            • +
          • Recent contact with an infectious TB case
            • +
          • Fibrous changes on chest radiograph consistent with prior TB
            • +
          • Patients with organ transplants and other immunosuppressed patients (receiving the equivalent of > 15 + mg/d of + prednisone for 1 month or more including patients who will + receive TNF-α inhibitors) +
            • +
          +
          + Reaction ≥ 10 mm of induration⌃ +
          • Recent immigrants to the U.S. (within the last 5 years) who came from high TB incidence countries
          • Injection drug users
            • @@ -49,7 +65,9 @@

            Reaction ≥ 10 mm of induration

          • Children < 5 years of age or infants, children, and adolescents exposed to adults at high risk
          • Recent TST conversion (increase of > 10 mm of induration within the past 2 years)
          -

          Reaction ≥ 15 mm of induration

          +
          + Reaction ≥ 15 mm of induration⌃ +
          • Persons with no risk factors for TB (ideally such persons should not be tested) @@ -59,8 +77,8 @@

            Reaction ≥ 15 mm of induration

            positive
          - - +
          +
          @@ -68,4 +86,5 @@

          Reaction ≥ 15 mm of induration

          + diff --git a/app/src/main/assets/pages/2_diagnostic_tests_for_latent_tb_infection_(ltbi)__c__two_step_testing_and_the_booster_reaction.html b/app/src/main/assets/pages/2_diagnostic_tests_for_latent_tb_infection_(ltbi)__c__two_step_testing_and_the_booster_reaction.html index 4fe6e75..46c6f50 100644 --- a/app/src/main/assets/pages/2_diagnostic_tests_for_latent_tb_infection_(ltbi)__c__two_step_testing_and_the_booster_reaction.html +++ b/app/src/main/assets/pages/2_diagnostic_tests_for_latent_tb_infection_(ltbi)__c__two_step_testing_and_the_booster_reaction.html @@ -15,7 +15,20 @@
          -

          In some persons (especially individuals > 50 years of age) with +

          +
          +
          +
          + +
          +

          II. Diagnostic Tests for Latent TB Infection (LTBI)

          +
          +

          Last Updated October 2025

          +
          +
          +
          + +

          In some persons (especially individuals > 50 years of age) with LTBI, delayed-type hypersensitivity reactions to tuberculin may wane over time. When a TST is performed years after infection has occurred, these persons may have an initial negative tuberculin skin test result. However, this initial @@ -26,14 +39,15 @@ true conversion due to recent infection. Two-step tuberculin skin testing is used to distinguish between boosted reactions and reactions due to new infection.

          -

          Two-step testing (at baseline) is recommended for employees or +

          Two-step testing (at baseline) is recommended for employees or residents in institutional settings (such as health care workers or correctional facility employees) who may undergo periodic tuberculin screening (and have not had a TST in the past year), and for whom it is important to distinguish between new infection and a boosted reaction from past infection.

          -

          Two-Step Testing

          +

          Two-Step Testing⌃

          +
          1. Place the first test with 0.1 ml (5 TU) of tuberculin.
          2. If the reaction to the first test is negative, give a @@ -64,4 +78,5 @@

            Two-Step Testing

            + diff --git a/app/src/main/assets/pages/2_diagnostic_tests_for_latent_tb_infection_(ltbi)__d__anergy_testing.html b/app/src/main/assets/pages/2_diagnostic_tests_for_latent_tb_infection_(ltbi)__d__anergy_testing.html index cfb1344..f334bc9 100644 --- a/app/src/main/assets/pages/2_diagnostic_tests_for_latent_tb_infection_(ltbi)__d__anergy_testing.html +++ b/app/src/main/assets/pages/2_diagnostic_tests_for_latent_tb_infection_(ltbi)__d__anergy_testing.html @@ -15,7 +15,19 @@
            -

            Anergy testing is not recommended for routine use in persons +

            +
            +
            +
            + +
            +

            II. Diagnostic Tests for Latent TB Infection (LTBI)

            +
            +

            Last Updated October 2025

            +
            +
            +
            +

            Anergy testing is not recommended for routine use in persons living with HIV or otherwise immunocompromised. Factors limiting the usefulness of anergy skin testing include problems with the standardization and reproducibility, the low risk for TB disease associated with a diagnosis of anergy, and the lack of apparent benefit of treatment of LTBI for groups of anergic HIV infected persons in diff --git a/app/src/main/assets/pages/2_diagnostic_tests_for_latent_tb_infection_(ltbi)__e__interferon_y_release_assays_(igras).html b/app/src/main/assets/pages/2_diagnostic_tests_for_latent_tb_infection_(ltbi)__e__interferon_y_release_assays_(igras).html index ca078af..661fa1d 100644 --- a/app/src/main/assets/pages/2_diagnostic_tests_for_latent_tb_infection_(ltbi)__e__interferon_y_release_assays_(igras).html +++ b/app/src/main/assets/pages/2_diagnostic_tests_for_latent_tb_infection_(ltbi)__e__interferon_y_release_assays_(igras).html @@ -15,19 +15,37 @@

            -

            +

            +
            +
            +
            + +
            +

            II. Diagnostic Tests for Latent TB Infection (LTBI)

            +
            +

            Last Updated October 2025

            +
            +
            +
            +

            Two FDA-approved IGRA tests are commercially available in the U.S. These include the QuantiFERON-TB Gold Plus (QFT) test and the TSPOT.TB (TSPOT) test. Guidelines on the use of these IGRAs as diagnostic tests for LTBI have been published by the American Thoracic Society (ATS), CDC, and the Infectious Diseases Society - of America (IDSA) [Clin Infect Dis 2017; 64(2):111–5]. IGRAs are invitro blood tests that are based on + of America (IDSA) [Clin Infect Dis 2017; 64(2):111–5].

            +

            + IGRAs are in vitro blood tests that are based on interferon-γ (IFN-γ) release after stimulation by relatively TB-specific antigens (i.e., ESAT-6 - and CFP-10 in both assays). The QFT is a whole blood assay that + and CFP-10 in both assays).

            +

            + The QFT is a whole blood assay that uses an ELISA technique to measure IFN-γ production. TSPOT uses peripheral blood mononuclear cells (PBMCs) and detects (by - use of ELISPOT) the number of T cells producing IFN-γ. Because + use of ELISPOT) the number of T cells producing IFN-γ.

            +

            + Because the antigens used in the IGRAs are not found in M. bovis BCG (or most non-tuberculous mycobacteria), the IGRAs are more specific than the TST when used to test persons who have received @@ -38,97 +56,184 @@ and Table 2.

            -

            Table 1. Interpretation Criteria for the QuantiFERON-TB Gold Plus Test (QFT-Plus)

            +

            Table 1. Interpretation Criteria for the QuantiFERON-TB Gold Plus Test (QFT-Plus)

            - +
            +
              +
              • +
              • +
              • +
            +
            + +
            - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - + + + + + + + + + + + + + + + + + + + + + + + +
            Nil (IU/ml)TB1 minus Nil (IU/ml)TB2 minus Nil (IU/ml)Mitogen minus NilQFT-Plus ResultReport/Interpretation
            < 8.0> 0.35 and > 25% of NilAnyAnyPositiveM. tuberculosis infection likely
            Any> 0.35 and > 25% of Nil
            < 0.35 or > 0.35 and < 25% of Nil< 0.35 or > 0.35 and < 25% of Nil> 0.50 NegativeM. tuberculosis infection NOT likely
            < 0.35 or > 0.35 and < 25 % of Nil< 0.35 or > 0.35 and < 25% of Nil< 0.50IndeterminateLikelihood of M. tuberculosis infection cannot be determined
            > 8.0Any
            Nil (IU/ml) < 8.0
            TB1 minus Nil (IU/ml)> 0.35 and > 25% of NilAny
            TB2 minus Nil (IU/ml)Any> 0.35 and > 25% of Nil
            Mitogen minus NilAny
            Report/InterpretationM. tuberculosis infection likely
            + + + + + + + + + + + + + + + + + + + + + + + +
            Nil (IU/ml) < 8.0
            TB1 minus Nil (IU/ml)< 0.35 or > 0.35 and < 25 % of Nil
            TB2 minus Nil (IU/ml)< 0.35 or > 0.35 and < 25% of Nil
            Mitogen minus Nil > 0.50
            Report/InterpretationM. tuberculosis infection not likely
            -
            -

            Source: Based on manufacturer recommendations for QuantiFERON-TB Gold Plus [Package insert].
            Available at: - - https://www.quantiferon.com/us/wp-content/uploads/sites/13/2020/01/L1095849-R06-QFT-Plus-ELISA-IFU.pdf

            -

            Table 2. Interpretation Criteria for the T-SPOT.TB Test (T-Spot)

            + + + + + + + + + + + + + + + + + + + + + + + + + + + +
            Nil (IU/ml) < 8.0> 8.0
            TB1 minus Nil (IU/ml)< 0.35 or > 0.35 and < 25% of NilAny
            TB2 minus Nil (IU/ml)< 0.35 or > 0.35 and < 25% of NilAny
            Mitogen minus Nil < 0.50Any
            Report/InterpretationLikelihood of M. tuberculosis infection cannot be determined
            +
            +

            + Source: Based on manufacturer recommendations for QuantiFERON-TB Gold Plus [Package insert].
            Available + at: + + https://www.qiagen.com/us/resources/resource?id=ac068fc7-a994-4443-ac7c-dda43ce2bc5e&lang=en +

            + +

            Table 2. Interpretation Criteria for the T-SPOT.TB Test (T-Spot)

            - - - - - - - - - +
            +
              +
              • +
              • +
              • +
              • +
            +
            + +
            InterpretationNil*TB Response†Mitogen§
            + + + + + + + + + + + + + + +
            Nil*≤ 10 spots
            TB Response†≥ 8 spots
            Mitogen§Any
            + + + + + + + + + + + + + + + + +
            Nil*< 10 spots
            TB Response†5, 6, or 7 spots
            Mitogen§Any
            + + + + + + + + + + + + + + + + +
            Nil*≤ 10 spots
            TB Response†> 20 spots
            Mitogen§> 20 spots
            + + - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - + + + + + + + + + + + + + + +
            Positive¶≤ 10 spots≥8 spotsAny
            Borderline**≤ 10 spots5, 6, or 7 spotsAny
            Negative†† ≤ 10 spots>20 spots>20 spots
            Invalid**≤ 10 spotsAnyAny
            ≤ 10 spots<5 spots<20 spots
            Nil*≤ 10 spots≤ 10 spots
            TB Response†Any< 5 spots
            Mitogen§Any< 20 spots
            @@ -136,8 +241,8 @@

            Table 2. Interpretation Criteria for the T-SPOT.TB Test (T-Spot)

            Source: Based on Oxford Immunotec T-Spot.TB package insert.
            Available at: - http://www.oxfordimmunotec.com/international/wp-content/uploads/sites/3/Final-File-PI-TB-US-V6.pdf + href="https://www.tspot.com/wp-content/uploads/2021/04/TB-PI-US-0001-V9.pdf" class="res-width"> + https://www.tspot.com/wp-content/uploads/2021/04/TB-PI-US-0001-V9.pdf

            @@ -161,4 +266,5 @@

            Table 2. Interpretation Criteria for the T-SPOT.TB Test (T-Spot) + diff --git a/app/src/main/assets/pages/2_diagnostic_tests_for_latent_tb_infection_(ltbi)__f__targeted_testing_and_diagnostic_tests_for_ltbi.html b/app/src/main/assets/pages/2_diagnostic_tests_for_latent_tb_infection_(ltbi)__f__targeted_testing_and_diagnostic_tests_for_ltbi.html index e2bf793..aa7db67 100644 --- a/app/src/main/assets/pages/2_diagnostic_tests_for_latent_tb_infection_(ltbi)__f__targeted_testing_and_diagnostic_tests_for_ltbi.html +++ b/app/src/main/assets/pages/2_diagnostic_tests_for_latent_tb_infection_(ltbi)__f__targeted_testing_and_diagnostic_tests_for_ltbi.html @@ -15,100 +15,141 @@
            +
            +
            +
            +
            + +
            +

            II. Diagnostic Tests for Latent TB Infection (LTBI)

            +
            +

            Last Updated October 2025

            +
            +
            +
            -

            +

            Diagnostic testing for LTBI should be targeted at those who are at increased risk for having LTBI and those who if infected with M. tuberculosis are at increased risk of progression to active TB - disease (see Table 3). HIV-infected persons with LTBI - have the greatest risk of progressing to active TB (at rates up to 8 - -10% per year). All persons living with HIV should undergo testing - for LTBI, and if LTBI is found, should strongly be encouraged to - initiate and complete treatment for LTBI.
            - Patients who take immunomodulating drugs are also at very high risk - for progression to active TB if infected with M. tuberculosis. This includes patients with LTBI who are treated - with TNF-α inhibitors such as - infliximab (Remicade), etanercept (Enbrel), adalimumab (Humira), - certolizumab pegol (Cimzia), or golimumab (Simponi). Following - the initial introduction of TNF-α inhibitor drugs, there were reports of the subsequent development of - extrapulmonary and disseminated disease and in some cases, death.
            - All patients who will be treated with TNF-α inhibitor drugs should be screened for - LTBI before starting the medication; if found to have LTBI, they - should be started on therapy for LTBI (after active TB is excluded) - before starting the TNF-α inhibitor. Whether treatment for LTBI - should be completed before a TNF-α inhibitor is started is controversial. Patients preparing to receive a solid - organ transplant should also be screened for LTBI.
            - There is no official guidance regarding LTBI testing pre-bone marrow transplant. Current clinical practice among - experts is to use targeted testing for LTBI based on epidemiologic risk factors. - Children less than 5 years of age are at increased risk for progression to active TB disease if - infected but should not be tested for LTBI unless they are at increased risk for TB exposure (see Table 3). - Persons who recently converted to a positive skin test (or positive IGRA) should be medically evaluated, and - active TB disease ruled out (see section II. G. page 21) and LTBI treatment considered. Also, persons with - a chest radiograph suggestive of old TB are at increased risk for - progression to active TB disease. + disease (see Table 3).

            + + People living with HIV who have LTBI⌃ +
            +
              +
            • are at the greatest risk of progressing to active TB disease (at rates up to 8 -10% per year). All persons living with HIV should undergo testing for LTBI, and if LTBI is found, should strongly be encouraged to initiate and complete treatment for LTBI.
              • +
            +
            -

            Who should be targeted for LTBI testing?

            -

            Diagnostic tests for LTBI are not recommended for people with - low risk of infection with M. tuberculosis. Testing of low-risk persons can result in false-positive tests. - Certain persons with increased risk of developing TB if they have LTBI should be targeted for testing. These - include:

            -
              + Patients who take immunomodulating drugs⌃ +
              +
                +
              • are also at increased risk for progression to active TB disease if infected with M. tuberculosis. This includes patients with LTBI who are treated with TNF-α inhibitors such as infliximab (Remicade), etanercept (Enbrel), adalimumab (Humira), certolizumab pegol (Cimzia), or golimumab (Simponi). Following the initial introduction of TNF-α inhibitor drugs, there were reports of the subsequent development of extrapulmonary and disseminated disease and in some cases, death.
                • +
              +
              + + All patients who will be treated with TNF-α inhibitor drugs⌃ +
              +
                +
              • should be screened for LTBI before starting the medication; if found to have LTBI, they should be started on therapy for LTBI (after active TB disease is excluded) before starting the TNF-α inhibitor. Whether treatment for LTBI should be completed before a TNF-α inhibitor is started is controversial.
                • +
              +
              + + Patients preparing to receive a solid organ transplant⌃ +
              +
                +
              • should also be screened for LTBI.
                • +
              • There is no official guidance regarding LTBI testing pre-bone marrow transplant, but most experts recommend screening, especially among with risk factors for LTBI.
                • +
              +
              + + Current clinical practice among experts is to use targeted testing for LTBI based on epidemiologic risk factors.⌃ +
              +
                +
              • Children less than 5 years of age are at increased risk for progression to active TB disease if infected but should not be tested for LTBI unless they are at increased risk for TB exposure (see Table 3 ).
                • +
              • Persons who recently converted to a positive skin test (or positive IGRA) should be medically evaluated, and + active TB disease ruled out (see section II. G. page 21) and LTBI treatment considered.
                • +
              • Also, persons with + a chest radiograph suggestive of old TB are at increased risk for + progression to active TB disease.
                • +
              +
              + +

              Who should be targeted for LTBI testing?

              + +

              Diagnostic tests for LTBI are not recommended for people with low risk of M. tuberculosis infection. Testing of low-risk persons can result in false-positive tests. +

              + + Certain persons with increased risk of developing TB if they have LTBI should be targeted for testing. These include:⌃ +
              +
              • People who have spent time with someone who has TB disease (contacts of active TB cases)
                • -
              • People living with HIV or those who have other immunecompromising illnessesImmigrants from high TB incidence - countries (e.g., Asia, Africa, most countries in Latin America, the Caribbean, Eastern Europe, and Russia) +
              • People living with HIV or those who have other immunecompromising illnesses.
                • +
              • + Immigrants from high TB incidence countries (e.g., Asia, Africa, most countries in Latin America, the Caribbean, Eastern Europe, and Russia)
              • People who live or work somewhere in the United States where TB disease is more common (homeless shelters, correctional facilities including prisons and jails, or some nursing homes)
                • -
              • People who use illegal drugs, especially injection drug users
                • +
              • People with substance use disorders including persons who inject drugs
              • People who are preparing to initiate treatment with a TNF-α inhibitor.
              • People preparing to receive a solid organ transplant or hematopoetic stem cell transplant.
                • -
              - - U.S. Preventive Services Task Force (USPSTF) Recommendations for Screening for Latent TB Infection - (LTBI): -
              - The U.S. Preventive Services Task Force (USPSTF) recommends +
            +
            +

            U.S. Preventive Services Task Force (USPSTF) Recommendations for Screening for Latent TB Infection + (LTBI):⌃

            +
            +
              +
            • The U.S. Preventive Services Task Force (USPSTF) recommends testing populations that are at increased risk for TB infection

              (https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/latent-tuberculosis-infection-screening)

              +
              • +
            • This is a “B” recommendation (“offer or provide this service”) indicating that given the current evidence, the USPSTF has concluded with moderate certainty that benefits of screening for LTBI in people who are at increased risk of infection outweigh - the potential harms. However, the highest-risk populations and - thus those with the greatest benefit for targeted screening and - treatment (persons living with HIV, close contacts of persons - with active TB, and those being treated with immunosuppressive - agents such as TNF-α inhibitors) were excluded from the USPSTF - review of evidence because “screening in these populations may - be considered standard care as part of disease management or - indicated prior to the use of certain medications.” Once these - highest-risk groups which should be screened for LTBI are removed, patients considered high risk in the primary - care setting - that should be screened for LTBI include non-U.S. born persons - who have immigrated to the U.S. from high burden TB countries. - - High-risk groups for TB infection that should be targeted for - testing and treatment are outlined above and also listed in - - Table 3. -
              -

              Table 3. High Prevalence and High-Risk Groups

              + the potential harms.
              • + +
            • + However, the highest-risk populations and thus those with the greatest benefit for targeted screening and treatment (persons living with HIV, close contacts of persons with active TB, and those being treated with immunosuppressive + agents such as TNF-α inhibitors) were excluded from the USPSTF + review of evidence because “screening in these populations may + be considered standard care as part of disease management or + indicated prior to the use of certain medications.” +
              • + +
            • + Once these highest-risk groups which should be screened for LTBI are removed, patients considered high risk in the primary + care setting that should be screened for LTBI include non-U.S. born persons + who have immigrated to the U.S. from high burden TB countries. +
              • + +
            • + + High-risk groups for TB infection that should be targeted for + testing and treatment are outlined above and also listed in + Table 3. +
              • +
            +
            + +

            Table 3. High Prevalence and High-Risk Groups

            - + - @@ -118,7 +159,7 @@

            Table 3. High Prevalence and High-Risk Groups

            Groups with a High Prevalence of Latent TB Infection Groups with a High Prevalence of Latent TB Infection  Groups with a High Risk of Progression to Active TB Disease if Infected with M. tuberculosis
            Persons born in countries with high rates of TBPersons living with HIV Persons who are close contacts of persons with infectious active TB + Persons living with HIV Persons who are close contacts of persons with infectious active TB 
            Persons who live or spend time in certain facilities (e.g., nursing homes, correctional institutions, - homeless shelters, drug treatment centers) + homeless shelters, drug treatment centers)  Persons with recent infection with M. tuberculosis (e.g., have had a diagnostic test result for LTBI convert to positive in the past 1-2 years) Persons who have chest radiographs suggestive of old TB @@ -130,89 +171,93 @@

            Table 3. High Prevalence and High-Risk Groups

            *Diabetes mellitus, silicosis, prolonged therapy with corticosteroids, immunosuppressive - therapy particularly TNF-α blockers, leukemia, Hodgkin’s disease, head and neck cancers, - severe kidney disease, certain intestinal conditions, malnutrition + therapy particularly TNF-α blockers, leukemia, Hodgkin’s disease, head and neck cancers, + severe kidney disease, certain intestinal conditions, malnutrition 
            From: MMWR 2010;59(RR-5):1-25 -

            Testing of low risk individuals for LTBI is discouraged because +

            Testing of low risk individuals for LTBI is discouraged because false-positive results are more likely to occur in this setting. Because QFT, TSPOT, and TST each measure different aspects of the immune response and use different antigens and interpretation criteria, test results might not be interchangeable. Different tests can yield different results. Studies which employed multiple diagnostic tests have demonstrated that discordant test results are not uncommon.

            + -

            Which diagnostic test for LTBI should be used?

            - General Recommendations for Use of Diagnostic Tests for LTBI: -
              -
            • ATS/CDC/IDSA guidelines [Clin Infect Dis 2017; 64(2):111–5] - note that either an FDA-approved IGRA (i.e., QFT or TSPOT) - or TST can be used for diagnostic testing, and use of either - test is an acceptable medical and public health practice. As - noted below, there are preferences and special circumstances in which one of these tests may be - preferred. -
              • -
            • The ATS/CDC/IDSA guidelines note that “There are insufficient data to recommend a preference for either - a TST or an - IGRA as the first-line diagnostic test in individuals 5 years or - older who are likely to be infected with M. tuberculosis, who - have a high risk of progression to disease, and in whom it - has been determined that diagnostic testing for LTBI is warranted.” -
              • -
            - Situations in which an IGRA is preferred but a TST is acceptable: -
              -
            • Testing of BCG-vaccinated persons (because of improved - specificity of the IGRA vs. TST in this population) -
              • -
            • Testing of persons who may be unlikely to return to have the - TST read (e.g., homeless individuals and injection drug users - or those with substance abuse) -
              • -
            +

            Which diagnostic test for LTBI should be used?

            + General Recommendations for Use of Diagnostic Tests for LTBI: ⌃ +
            +
              +
            • ATS/CDC/IDSA guidelines [Clin Infect Dis 2017; 64(2):111–5] + note that either an FDA-approved IGRA (i.e., QFT or TSPOT) + or TST can be used for diagnostic testing, and use of either + test is an acceptable medical and public health practice. As + noted below, there are preferences and special circumstances in which one of these tests may be + preferred. +
              • +
            • The ATS/CDC/IDSA guidelines note that “There are insufficient data to recommend a preference for either + a TST or an + IGRA as the first-line diagnostic test in individuals 5 years or + older who are likely to be infected with M. tuberculosis, who + have a high risk of progression to disease, and in whom it + has been determined that diagnostic testing for LTBI is warranted.” +
              • +
            +
            - Situations in which a TST is preferred but an IGRA is acceptable: -
              -
            • Testing children aged < 5 years (TST is recommended by the - American Academy of Pediatrics) -
              • -
            • Serial testing (e.g., for selected health care workers). While - not a CDC recommendation, we recommend that the TST be - used for serial testing programs. Several reports have indicated very high rates of diagnostic test - "conversion" (e.g., up - to 10-fold higher than the TST) when IGRAs were used for - serial testing of health care workers in low-risk/lowprevalence situations in the U.S. and Canada (thus - suggesting the IGRA results were false positive). Most health care - workers in the U.S. are at low risk for occupational infection - with M. tuberculosis and national guidelines on serial testing - of health care workers have recently been updated by CDC - based on the changing epidemiology of TB in the U.S. over - the past few decades. These updated CDC guidelines no - longer recommend routine serial screening of low-risk U.S. - health care workers in the absence of exposure or ongoing - transmission. Baseline testing at the time of employment is - recommended. -
              • -
            - Situations in which a TST or IGRA may be used without preference: + Situations in which an IGRA is preferred but a TST is acceptable: ⌃ +
            +
              +
            • Testing of BCG-vaccinated persons (because of improved + specificity of the IGRA vs. TST in this population) +
              • +
            • Testing of persons who may be unlikely to return to have the TST read (e.g., people experiencing homelessness, persons with substance use disorders, and persons who inject drugs) +
              • +
            +
            + + Situations in which a TST is preferred but an IGRA is acceptable: ⌃ +
            +
              +
            • Testing children aged < 5 years (TST is recommended by the + American Academy of Pediatrics) +
              • +
            • Serial testing (e.g., for selected health care workers). While + not a CDC recommendation, we recommend that the TST be + used for serial testing programs. Several reports have indicated very high rates of diagnostic test + "conversion" (e.g., up + to 10-fold higher than the TST) when IGRAs were used for + serial testing of health care workers in low-risk/lowprevalence situations in the U.S. and Canada (thus + suggesting the IGRA results were false positive). Most health care + workers in the U.S. are at low risk for occupational infection + with M. tuberculosis and national guidelines on serial testing + of health care workers have recently been updated by CDC + based on the changing epidemiology of TB in the U.S. over + the past few decades. These updated CDC guidelines no + longer recommend routine serial screening of low-risk U.S. + health care workers in the absence of exposure or ongoing + transmission. Baseline testing at the time of employment is + recommended. +
              • +
            +
            + Situations in which a TST or IGRA may be used without preference: ⌃ +
              -
            • Contact investigations (i.e., testing of recent contacts of - persons known or suspected to have active TB) +
            • Contact investigations (i.e., testing of recent contacts of persons known or suspected to have active TB disease)
            +
            - Situations in which testing with both an IGRA and a TST may be - considered: + Situations in which testing with both an IGRA and a TST may be + considered: ⌃ +
              -
            • When additional evidence of infection is required to encourage a person that they have LTBI and should - take and adhere - to therapy for LTBI (e.g., foreign-born health care worker - who believes that their positive TST result is attributable to - BCG) +
            • When additional evidence of infection is required to encourage a person that they have LTBI and should take and adhere to therapy for LTBI (e.g., non-US born health care worker who believes that their positive TST result is attributable to BCG)
            • When the initial diagnostic test performed in a healthy person at low risk for both infection and progression is positive @@ -227,7 +272,6 @@

              Which diagnostic test for LTBI should be used?

            • In selected very high-risk individuals when missing the presence of LTBI could have serious consequences (e.g., individuals to be started on a TNF-α blocker or other immunocompromising medications).
              • -
            @@ -236,4 +280,5 @@

            Which diagnostic test for LTBI should be used?

            + diff --git a/app/src/main/assets/pages/2_diagnostic_tests_for_latent_tb_infection_(ltbi)__g__medical_evaluation_after_testing_for_ltbi.html b/app/src/main/assets/pages/2_diagnostic_tests_for_latent_tb_infection_(ltbi)__g__medical_evaluation_after_testing_for_ltbi.html index d5d054c..d1e8a3f 100644 --- a/app/src/main/assets/pages/2_diagnostic_tests_for_latent_tb_infection_(ltbi)__g__medical_evaluation_after_testing_for_ltbi.html +++ b/app/src/main/assets/pages/2_diagnostic_tests_for_latent_tb_infection_(ltbi)__g__medical_evaluation_after_testing_for_ltbi.html @@ -15,84 +15,86 @@
            +
            +
            +
            +
            + +
            +

            II. Diagnostic Tests for Latent TB Infection (LTBI)

            +
            +

            Last Updated October 2025

            +
            +
            +
            -
              -
            • Neither an IGRA nor a TST can distinguish LTBI from active - TB disease. A negative IGRA or TST does not rule out active TB - disease. -
              • -
            • Persons with a positive IGRA or TST should be evaluated for - the likelihood of M. tuberculosis infection, for risks for progression to active TB if infected, and for - symptoms and signs of - active TB. -
              • -
            • A diagnosis of LTBI requires that active TB be excluded by - medical evaluation which should include taking a medical - history and a physical exam to check for suggestive symptoms - and signs, a chest x-ray (CXR), and when indicated, testing of - sputum or other clinical samples for the presence of M. tuberculosis. -
              • -
            • Persons with a newly documented diagnostic test for LTBI - (positive IGRA or TST) should have a chest x-ray performed to - ensure that they do not have active TB disease. After an initial - negative chest x-ray, no routine follow-up chest x-rays are - necessary. Persons with a positive diagnostic test for LTBI - should be educated about the signs and symptoms of active TB - disease and instructed to consult with a physician if these - symptoms occur. -
              • +

              Neither an IGRA nor a TST can distinguish LTBI from active + TB disease. A negative IGRA or TST does not rule out active TB + disease.

              + + Persons with a positive IGRA or TST⌃ +
              +
                +
              • should be evaluated for the likelihood of M. tuberculosis infection, for risks for progression to active TB if infected, and for symptoms and signs of active TB disease. +
                • +
              +
              -
            • In healthy persons who have a low likelihood both of M. tuberculosis infection and of progression to active - TB disease if infected, a single positive IGRA or TST result should not be taken - as reliable evidence of M. tuberculosis infection. Because of the low probability of infection, a - false-positive result is more likely. In such situations, the likelihood of M. tuberculosis infection - and of disease progression should be reassessed, and the initial - test results should be confirmed. Repeat testing, with either - the initial test or a different test, may be considered on a caseby-case basis. For such persons, an - alternative is to assume, - without additional testing, that the initial result is a false positive. This becomes somewhat complex - because of the lack of a - “gold standard” diagnostic test for LTBI. For healthy persons - who have a low risk for both infection and progression, discounting an isolated positive result as a false - positive may be - reasonable. This will increase detection specificity and decrease unnecessary treatment. -
              • + A diagnosis of LTBI requires that active TB be excluded by medical evaluation⌃ +
              +
                +
              • which should include taking a medical history and a physical exam to check for suggestive symptoms and signs, a chest x-ray (CXR), and when indicated, testing of sputum or other clinical samples for the presence of M. tuberculosis. +
                • +
              +
              -
            • - In persons with discordant test results (i.e., one positive and - the other negative), decisions about medical or public health - management require individualized judgment in assessing the - quality and magnitude of each test result (e.g., size of induration and presence of blistering for a TST; - and the TB Response, - Nil, and Mitogen values for an IGRA), the probability of infection, the risk for disease if infected, and - the risk for a poor - outcome if disease occurs. Patients who are at high risk for - progression to active TB when LTBI is present (e.g., persons - living with HIV, those scheduled to begin a TNF-α inhibitor, - children < 5 years) should be assumed to have LTBI if one diagnostic test is positive (even if there are - discordant results). For - persons who have received BCG and who are not at increased - risk for a poor outcome if infected, TST reactions of < 15 mm in - size may reasonably be discounted as false positives when an - IGRA is negative. In other situations, inadequate evidence exists on which to base recommendations for - dealing with discordant results. Consultation with a TB expert should be considered when discordant results - are present. -
              • + Persons with a newly documented diagnostic test for LTBI (positive IGRA or TST)⌃ +
              +
                +
              • should have a chest x-ray performed to ensure that they do not have active TB disease. After an initial negative chest x-ray, no routine follow-up chest x-rays are necessary. Persons with a positive diagnostic test for LTBI should be educated about the signs and symptoms of active TB disease and instructed to consult with a physician if these symptoms occur. +
                • +
              +
              -
            • Persons with a positive diagnostic test for LTBI who have active TB excluded, should be considered for - treatment of LTBI. - Treatment of LTBI is recommended for those at increased risk - of progression to active TB disease (see - Table - 3). Treatment - regimens for LTBI are described in the following pages. -
              • -
            + In healthy persons who have a low likelihood both of M. tuberculosis infection and of progression to active + TB disease if infected⌃ +
            +
              +
            • a single positive IGRA or TST result should not be taken as reliable evidence of M. tuberculosis infection.
              • +
            • Because of the low probability of infection, a false-positive result is more likely. In such situations, the likelihood of M. tuberculosis infection and of disease progression should be reassessed, and the initial test results should be confirmed.
              • +
            • Repeat testing, with either the initial test or a different test, may be considered on a case-by-case basis. For such persons, an alternative is to assume, without additional testing, that the initial result is a false positive. This becomes somewhat complex because of the lack of a “gold standard” diagnostic test for LTBI.
              • +
            • For healthy persons who have a low risk for both infection and progression, discounting an isolated positive result as a false positive may be reasonable. This will increase detection specificity and decrease unnecessary treatment.
              • +
            +
            + In persons with discordant test results (i.e., one positive and the other negative)⌃ +
            +
              +
            • decisions about medical or public health management require individualized judgment in assessing the quality and magnitude of each test result (e.g., size of induration and presence of blistering for a TST; and the TB Response, Nil, and Mitogen values for an IGRA), the probability of infection, the risk for disease if infected, and the risk for a poor + outcome if disease occurs.
              • +
            • Patients who are at high risk for progression to active TB disease when LTBI is present (e.g., persons living with HIV, those scheduled to begin a TNF-α inhibitor, children < 5 years) should be assumed to have LTBI if one diagnostic test is positive (even if there are discordant results).
              • +
            • For persons who have received BCG and who are not at increased risk for a poor outcome if infected, TST reactions of < 15 mm in size may reasonably be discounted as false positives when an IGRA is negative.
              • +
            • In other situations, inadequate evidence exists on which to base recommendations for dealing with discordant results. Consultation with a TB expert should be considered when discordant results are present.
              • +
            +
            + Persons with a positive diagnostic test for LTBI who have active TB disease excluded⌃ +
            +
              +
            • should be considered for + treatment of LTBI. + Treatment of LTBI is recommended for those at increased risk + of progression to active TB disease (see + Table + 3). Treatment + regimens for LTBI are described in the following pages. +
              • +
            +
            + diff --git a/app/src/main/assets/pages/2_diagnostic_tests_for_latent_tb_infection_(ltbi)__h__reporting_of_pediatric_positive_tests_for_ltbi.html b/app/src/main/assets/pages/2_diagnostic_tests_for_latent_tb_infection_(ltbi)__h__reporting_of_pediatric_positive_tests_for_ltbi.html index 6cb97b1..5563ebb 100644 --- a/app/src/main/assets/pages/2_diagnostic_tests_for_latent_tb_infection_(ltbi)__h__reporting_of_pediatric_positive_tests_for_ltbi.html +++ b/app/src/main/assets/pages/2_diagnostic_tests_for_latent_tb_infection_(ltbi)__h__reporting_of_pediatric_positive_tests_for_ltbi.html @@ -15,7 +15,20 @@
            -

            Latent TB infection (LTBI) in children indicates recent transmission of TB in the community. Also, young children +

            +
            +
            +
            + +
            +

            II. Diagnostic Tests for Latent TB Infection (LTBI)

            +
            +

            Last Updated October 2025

            +
            +
            +
            + +

            Latent TB infection (LTBI) in children indicates recent transmission of TB in the community. Also, young children who are infected with TB are at high risk of progressing to TB disease. Because of the extreme importance of identifying children who have been exposed to and infected with TB, LTBI in a child less than 5 diff --git a/app/src/main/assets/pages/3_treatment_of_latent_tb_infection_(ltbi).html b/app/src/main/assets/pages/3_treatment_of_latent_tb_infection_(ltbi).html index 89acaef..b907264 100644 --- a/app/src/main/assets/pages/3_treatment_of_latent_tb_infection_(ltbi).html +++ b/app/src/main/assets/pages/3_treatment_of_latent_tb_infection_(ltbi).html @@ -15,7 +15,19 @@

            -

            Treatment of LTBI is recommended for persons who are at increased risk for developing active TB disease. Those at +

            +
            +
            +
            + +
            +

            III. Treatment of Latent TB Infection (LTBI)

            +
            +

            Last Updated October 2025

            +
            +
            +
            +

            Treatment of LTBI is recommended for persons who are at increased risk for developing active TB disease. Those at increased risk for developing active TB disease following infection with M. tuberculosis are outlined in + children at risk who are < 5 years old. +

            +

            The risk of serious disease, including miliary or disseminated TB and tuberculous meningitis, is highest among persons living with HIV, especially if they have @@ -41,8 +55,9 @@ href="table_3_high_prevalence_and_high_risk_groups.html">Table 3) should be offered (and encouraged to take) treatment for LTBI irrespective of age.

            -

            List of sub chapters

            -
              +
              +

              List of sub chapters

              + -

              List of charts

              -
                +

                List of charts

                +
                • Table 4. Recommendations for Regimens to Treat Latent Tuberculosis Infection
                • Table 5. Dosages for Recommended LTBI Treatment Regimens
                  • diff --git a/app/src/main/assets/pages/3_treatment_of_latent_tb_infection_(ltbi)__a__treatment_regimens.html b/app/src/main/assets/pages/3_treatment_of_latent_tb_infection_(ltbi)__a__treatment_regimens.html index 5ce5300..11dd96e 100644 --- a/app/src/main/assets/pages/3_treatment_of_latent_tb_infection_(ltbi)__a__treatment_regimens.html +++ b/app/src/main/assets/pages/3_treatment_of_latent_tb_infection_(ltbi)__a__treatment_regimens.html @@ -15,105 +15,101 @@
                  -

                  +

                  +
                  +
                  +
                  + +
                  +

                  III. Treatment of Latent TB Infection (LTBI)

                  +
                  +

                  Last Updated October 2025

                  +
                  +
                  +
                  + +

                  Treatment regimens for LTBI are outlined in Table 4. Several - different LTBI treatment regimens are recommended by CDC. + different LTBI treatment regimens are recommended by CDC and the National Tuberculosis Coalition of America (NTCA).

                  -
                  These include:
                  - -
                    -
                  • Rifampin.Rifampin for 4 months is a preferred CDC treatment regimen for the treatment of LTBI among - persons - presumed to be infected with drug-susceptible TB (INH and - rifampin susceptible) and is the regimen of choice for the - treatment of LTBI among persons thought to be infected - with INH-resistant strains. Rifampin is also preferred by - many clinicians and public health clinics because of the - shorter duration of therapy compared to INH. Rifampin has - less hepatotoxicity compared to INH for the treatment of - LTBI. Rifampin for 4 months has been shown to be noninferior to 9 months of INH for the treatment of LTBI in - a - randomized controlled trial. In addition, rifampin was associated with higher completion rates and fewer - adverse effects compared to INH. Rifampin has a large number of drug - -drug interactions (as discussed on page 78 ) including warfarin, oral contraceptives, azole antifungals, - and HIV antiretroviral therapy. Other medications that a person with - LTBI is taking is an important consideration when determining whether rifampin or other LTBI regimens which - include - rifampin or other rifamycins can be prescribed. Drug-drug - interactions between rifamycins and antiretroviral therapy - are regularly updated by the U.S. Department of Health and - Human Services (https://aidsinfo.nih.gov/guidelines/html/4/adult-and-adolescent-opportunistic-infection/0). + +

                    These include:

                    + +
                      +
                    • + + Rifampin⌃ + + +
                      + Rifampin for 4 months is a preferred CDC treatment regimen for the treatment of LTBI among persons presumed to be infected with drug-susceptible TB (isoniazid [INH] and rifampin susceptible) and is the regimen of choice for the treatment of LTBI among persons thought to be infected with INH-resistant strains + of M. tuberculosis. Rifampin is also preferred by many clinicians and public health clinics because of the shorter duration of therapy compared to INH and because rifampin has less hepatotoxicity compared to INH for the treatment of LTBI. + + Rifampin for 4 months has been shown to be noninferior to 9 months of INH for the treatment of LTBI in a randomized controlled trial. In addition, rifampin was associated with higher completion rates and fewer adverse effects compared to INH. Rifampin has a large number of drug -drug interactions (as discussed on page 78) + including warfarin, oral contraceptives, azole antifungals, and HIV antiretroviral therapy. Other medications that a person with LTBI is taking is an important consideration when determining whether rifampin or other LTBI regimens which include rifampin or other rifamycins can be prescribed. Drug-drug interactions between + rifamycins and antiretroviral therapy are regularly updated by the U.S. Department of Health and Human Services + (for LTBI regimens and rifampin/rifamycins: https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-opportunistic-infections/mycobacterium ); + rifampin and antiretroviral drug interactions: https://clinicalinfo.hiv.gov/sites/default/files/guidelines/documents/adult-adolescent-arv/guidelines-adult-adolescent-arv.pdf +
                      • -
                    • INH plus Rifapentine (3HP). A short course regimen of - weekly INH plus rifapentine for 12 weekly doses is another - CDC-preferred regimen for the treatment of LTBI (due to presumed infection with drug-susceptible M. - tuberculosis) in - adults as well as children > 2 years of age. In 2011, CDC first - recommended 3HP for the treatment of LTBI and that it be - by directly observed therapy [DOT]. However, based on - recent studies and updated data, CDC revised guidelines for - the use of 3HP in 2018 and expanded the patient populations - for which this regimen could be used and included an option - for self-administration of the 3HP regimen. CDC recommendations for 3HP in the treatment of LTBI include: -
                        -
                      • use of 3HP in adults and persons aged 2–17 years with - LTBI; -
                        • -
                      • use of 3HP in persons who are living with HIV with - LTBI including those with AIDS and taking antiretroviral medications with acceptable drug-drug - interactions with rifapentine* [the 2021 DHHS guidelines on treatment of HIV among adults and - adolescents indicate that rifapentine as part of a 3HP regimen is acceptable to use among persons - living with HIV on and ART regimen that includes once daily dolutegravir]; and -
                        • -
                      • - use of 3HP by directly observed therapy (DOT) or self-administered - therapy (SAT) in persons aged ≥ 2 - years. Per CDC recommendations, “the health care - provider should choose the mode of administration - (DOT versus SAT) based on local practice, individual - patient attributes and preferences, and other considerations, including risk for progression to - severe - forms of TB disease” (MMWR 2018; 67:723-72). - -
                        • -
                      - The 3HP is regimen is NOT recommended for pregnant - women, children < 2 years old, persons living with HIV who - are on antiretroviral drugs that have significant drug-drug interactions with rifapentine, or patients - infected with suspected INH-resistant, rifampin-resistant, or MDR isolates. - Other potential challenges in using the 3HP regimen in addition to the drug-drug interactions due to - rifapentine (similar - to those seen with other rifamycin drugs such as rifampin) - include cost of medications that are greater than most alternatives; the need to take numerous pills - simultaneously (10 - pills once weekly compared with two or three pills daily for - other regimens for most adults); and the association with a - systemic drug reaction or influenza-like syndrome that can - include syncope and hypotension (although the risk of hospitalization is low, 0.1% in published studies). +
                    • INH plus Rifapentine (3HP) ⌃ +
                      +

                      A short course regimen of weekly INH plus rifapentine for 12 weekly doses is another CDC-preferred + regimen for the treatment of LTBI (due to presumed infection with drug-susceptible M. tuberculosis) in adults as well as children > 2 years of age. + In 2011, when CDC first recommended 3HP for the treatment of LTBI it indicated it should be delivered by directly observed therapy [DOT]. However, based on further studies and updated data, CDC revised guidelines for the use of 3HP in 2018 expanded the patient populations for which this regimen could be used and included an option for self-administration of the 3HP regimen. CDC recommendations for 3HP in the treatment of LTBI include:

                      +
                        +
                      • use of 3HP in adults and persons aged 2–17 years with + LTBI; +
                        • +
                      • use of 3HP in persons who are living with HIV with + LTBI including those with AIDS and taking antiretroviral medications with acceptable drug-drug + interactions with rifapentine* [the 2021 DHHS guidelines on treatment of HIV among adults and + adolescents indicate that rifapentine as part of a 3HP regimen is acceptable to use among persons + living with HIV on and ART regimen that includes once daily dolutegravir]; and +
                        • +
                      • + use of 3HP by directly observed therapy (DOT) or self-administered + therapy (SAT) in persons aged ≥ 2 + years. Per CDC recommendations, “the health care + provider should choose the mode of administration + (DOT versus SAT) based on local practice, individual + patient attributes and preferences, and other considerations, including risk for progression to + severe + forms of TB disease” (MMWR 2018; 67:723-72). + +
                        • +
                      +

                      + The 3HP is regimen is NOT recommended for pregnant women, children < 2 years old, persons living with HIV who are on antiretroviral + drugs that have significant drug-drug interactions with rifapentine, or patients infected with suspected INH-resistant, + rifampin-resistant, or multidrug resistant (MDR) isolates. Other potential challenges in using the 3HP regimen in addition to + the drug-drug interactions due to rifapentine (similar to those seen with other rifamycin drugs such as rifampin) include cost of + medications that are greater than most alternatives; the need to take numerous pills simultaneously (10 pills once weekly + compared with two or three pills daily for other regimens for most adults); and the association with a systemic drug + reaction or influenza-like syndrome that can include syncope and hypotension (although the risk of hospitalization is low, 0.1% in published studies). +

                      +
                      • -
                    • Isoniazid (INH). In the CDC 2020 LTBI treatment guidelines, 6 or 9 months of daily INH is a - recommended alternative regimen for the treatment of LTBI (due to presumed - infection with drug susceptible M. tuberculosis) as shown in - Table 4. A regimen of 6 months of daily INH is strongly recommended for HIV-negative adults and children of - all ages - and conditionally recommended for HIV-positive adults and - children of all ages; INH daily for 9 months is conditionally - recommended for adults and children of all ages, both HIV-seronegative and HIV-positive. One practical approach - for the - use of INH for LTBI is to aim for a 9 month regimen with the - goal of completion of at least 6 months. INH can be given - daily (e.g., by self-administered therapy) or twice weekly (if - given by directly observed therapy) as outlined in Table 5. - INH should be used for the treatment of LTBI when there - are serious potential drug-drug interactions with rifampin - or other rifamycins. +
                    • Isoniazid (INH) ⌃ +
                      +

                      + In the CDC 2020 LTBI treatment guidelines, 6 or 9 months of daily INH is a recommended alternative regimen for the treatment of + LTBI (due to presumed infection with drug susceptible M. tuberculosis) as shown in Table 4. A regimen of 6 months of daily INH + is strongly recommended for HIV-negative adults and children of all ages and conditionally recommended for adults living with + HIV and children of all ages; INH daily for 9 months is conditionally recommended for adults and children of all ages, both + HIV-seronegative and HIV-positive. One practical approach for the use of INH for LTBI is to aim for a 9 month regimen with the + goal of completion of at least 6 months. INH can be given daily (e.g., by self-administered therapy) as outlined in Table 5. + INH should be used for the treatment of LTBI when there are serious potential drug-drug interactions with rifampin or other rifamycins. +

                      +
                      • -
                    • Isoniazid (INH) plus Rifampin. A regimen of 3 months of +
                    • Isoniazid (INH) plus Rifampin ⌃ +
                      + A regimen of 3 months of daily INH plus daily rifampin is a CDC conditionally recommended regimen for the treatment of LTBI in adults and children of all ages. Because this regimen contains rifampin, @@ -121,54 +117,65 @@
                      These include:
                      drug-drug interactions that would prohibit the use of this regimen (as discussed above for rifampin). +
                      • -
                    +
                  + + Pills -

                  Table 4. Recommendations for regimens to treat latent tuberculosis infection

                  +

                  Table 4. Recommendations for regimens to treat latent tuberculosis infection

                  - - - - - - - - - +
                  +
                    +
                    • +
                    • +
                  +
                  + +
                  Priority rank* RegimenRecommendation (strong or conditional)Evidence (high, moderate, low, or very low)
                  - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - + + + + + + + + + + + + + + + + + + + +
                  Preferred3 months isoniazid plus rifapentine given once weeklyStrongModerate
                  4 months rifampin given dailyModerate (HIV negative)†
                  3 months isoniazid plus rifampin given dailyConditionalVery low (HIV negative)
                  Low (HIV positive)
                  Alternative6 months isoniazid given dailyStrong§Moderate (HIV negative
                  ConditionalModerate (HIV positive)
                  9 months isoniazid given dailyModerate
                  Regimes3 months isoniazid plus rifapentine given once weekly4 months rifampin given daily3 months isoniazid plus rifampin given daily
                  Recommendation (Strong or Conditional)StrongStrongConditional
                  Evidence (High, Moderate, Low, or Very Low)ModerateModerate (HIV negative) † Very low (HIV negative) †
                  + + + + + + + + + + + + + + + + + + + + +
                  Regimes6 months isoniazid given daily9 months isoniazid given daily3 months isoniazid plus rifampin given daily
                  Recommendation (Strong or Conditional)Strong §ConditionalConditional
                  Evidence (High, Moderate, Low, or Very Low)Moderate (HIV negative)Moderate (if living with HIV)Moderate
                  @@ -185,196 +192,231 @@

                  Table 4. Recommendations for regimens to treat latent tuberculos regimen (e.g., due to drug intolerability or drug-drug interactions).

                  -

                  Table 5. Dosages for Recommended LTBI Treatment Regimens

                  +

                  Table 5. Dosages for Recommended LTBI Treatment Regimens

                  -

                  - * Isoniazid is formulated as 100-mg and 300-mg tablets.
                  - † Rifapentine is formulated as 150-mg tablets in blister packs that should be kept - sealed until use.
                  - § Intermittent regimens must be provided via directly observed therapy (i.e., a - health care worked observes the ingestion of medication).
                  - ¶ Rifampin (rifampicin) is formulated as 150-mg and 300-mg capsules.
                  - ** The American Academy of Pediatrics acknowledges that some experts use - rifampin at 20 - 30 mg/kg for the daily regimen when prescribing for infants and - toddlers. (Source: American Academy of Pediatrics. Tuberculosis. In: Kimberlin - DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the - Committee on Infectious Diseases. 31st ed. Itasca, IL: American Academy of - Pediatrics; 2018:829-53).
                  - †† The American Academy of Pediatrics recommends an isoniazid dosage of - 10 - 15 mg/kg for the daily regimen and 20 - 30 mg/kg for the twice-weekly - regimen. -
                  - Adapted from MMWR Recomm Rep 2020; 69(1):1-11. +

                  + * Isoniazid is formulated as 100-mg and 300-mg tablets. † Rifapentine is formulated as 150-mg tablets in blister packs that should be kept sealed until use. Rifapentine should not be used for children <2 years of age due to lack of pharmacokinetic data.¶ Rifampin (rifampicin) is formulated as 150-mg and 300-mg capsules. 
 ** The American Academy of Pediatrics acknowledges that some experts use rifampin at 20 - 30 mg/kg for the daily regimen when prescribing for infants and toddlers. (Source: American Academy of Pediatrics. Tuberculosis. In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases. 31st ed. Itasca, IL: American Academy of Pediatrics; 2018:829-53). †† The American Academy of Pediatrics recommends an isoniazid dosage of 10 - 15 mg/kg for the daily regimen. Adapted from MMWR Recomm Rep 2020; 69(1):1-11.

                  -

                  Table 6. LTBI Treatment Drug Adverse Reactions

                  +

                  Table 6. LTBI Treatment Drug Adverse Reactions

                  - - - - - - - - - +
                  +
                    +
                    • +
                    • +
                    • +
                  +
                  + +
                  DrugAdverse ReactionsMonitoringComments
                  + + + + + + + + + + + + + + +
                  Adverse Reactions + Gastrointestinal (GI) upset, hepatic enzyme elevations, hepatitis, peripheral neuropathy, mild effects on central nervous system (CNS), drug interactions +
                  + Monitoring + + Order baseline hepatic chemistry blood tests (at least AST or ALT) for patients with specific conditions: Living with HIV, liver disorders, postpartum period (<3 months after delivery), regular alcohol use, injection drug use, or use of medications with known possible interactions. [Some clinicians prefer to obtain baseline tests on all adults]. Repeat measurements if: * baseline results are abnormal * client is at high-risk for adverse reactions * client has symptoms of adverse reactions +
                  + Comments + + Hepatitis risk increases with age and alcohol consumption. Pyridoxine can prevent isoniazid-induced peripheral neuropathy. +
                  + + + + + + + + + + + + + + + + +
                  Adverse Reactions + Orange discoloration of body fluids (secretions, tears, urine) , GI upset, drug interactions, hepatitis, thrombocytopenia, rash, fever, influenza-like symptoms, hypersensitivity reaction* Many drug-drug interactions +
                  + Monitoring + + Complete blood count (CBC), platelets and liver function tests. + Repeat measurements if: * baseline results are abnormal * client has symptoms of adverse reactions  Prior to starting RIF or RPT: need to carefully review all medications being taken by the patient with LTBI and ensure there is no contraindication to the use of that medication and RIF, RBT or RPT. +
                  + Comments + + Hepatitis risk increases with age and alcohol consumption. Rifampin monotherapy is associated with lower risk of hepatotoxicity compared to INH monotherapy for patients being treated for LTBI. Need to carefully review for possible drug-drug interactions prior to starting RIF, RBT or RPT and ensure there are no contraindications to these agents prior to using them for the treatment of LTBI.
                  + + - - - - - - - - - - - - - - - - - - + + + + + + + + + + + +
                  Isoniazid (INH)Gastrointestinal (GI) upset, hepatic enzyme elevations, hepatitis, peripheral - neuropathy, mild effects on central nervous system (CNS), drug interactions - Order baseline hepatic chemistry blood tests (at least AST or ALT) for patients with the following - specific conditions: HIV infection, liver disorders, postpartum period (≤ 3 months after - delivery), regular alcohol use, injection drug use, or use of medica-tions with known possible inter - -actions.
                  -
                  - [some providers prefer to obtain baseline tests on all adults].
                  -
                  - Repeat measurements if: * baseline results are abnormal * client is at high-risk for adverse - reactions * client has symptoms of adverse reactions -                   		Hepatitis risk increases with age and alcohol consumption. Pyridoxine can prevent isoniazid-induced - peripheral neuropathy. -
                  Rifampin (RIF) and Rifapentine (RPT)Orange discoloration of body fluids (secretions, tears, urine) , GI upset, drug - interactions, hepatitis, thrombocytopenia, rash, fever, influenza-like symptoms, hypersensitivity - reaction* Many drug-drug interactionsComplete blood count (CBC), platelets and liver function tests.
                  - Repeat measurements if: * baseline results are abnormal * client has symptoms of adverse - reactions Prior to starting RIF or RPT: need to carefully review all medications - being taken by the patient with LTBI and ensure there is no contraindication to the use of that - medication and RIF or RPT. -                   		Hepatitis risk increases with age and alcohol consumption. Rifampin monotherapy is associated with - lower risk of hepatotoxicity compared to INH monotherapy for patients being treated for LTBI. Need - to carefully review for possible drug-drug interactions prior to starting RIF or RPT and ensure - there are no contraindications to these agents prior to using them for the treatment of LTBI. -
                  Isoniazid plus rifapentine (3HP)See adverse effects associated with isoniazid alone and a rifamycin alone (see above) See above recommendations for isoniazid and rifamycin drugsApproximately 4% of all patients using 3HP experience flu-like or other systemic drug reactions, - with fever, headache, dizziness, nausea, muscle and bone pain, rash, itching, red eyes, or other - symptoms. Approximately 5% of persons discontinue 3HP because of adverse events, including systemic - drug reactions; these reactions typically occur after the first 3–4 doses, and begin - approximately 4 hours after ingestion of medication. -
                  Adverse ReactionsSee adverse effects associated with isoniazid alone and a rifamycin alone (see above)
                  MonitoringComplete blood count (CBC), platelets and liver function tests. + Repeat measurements if: * baseline results are abnormal * client has symptoms of adverse reactions  Prior to starting RIF or RPT: need to carefully review all medications being taken by the patient with LTBI and ensure there is no contraindication to the use of that medication and RIF or RPT.
                  CommentsApproximately 4% of all patients using 3HP experience flu-like or other systemic drug reactions, with fever, headache, dizziness, nausea, muscle and bone pain, rash, itching, red eyes, or other symptoms. Approximately 5% of persons discontinue 3HP because of adverse events, including systemic drug reactions; these reactions typically occur after the first 3–4 doses, and begin approximately 4 hours after ingestion of medication.

                  - * Hypersensitivity reaction to rifamycins (rifampin or rifapentine): reactions may - include a flu-like syndrome (e.g. fever, chills, headaches, dizziness, musculoskeletal pain), - thrombocytopenia, shortness of breath or other signs and symptoms including wheezing, acute bronchospasm, - urticaria, petechiae, purpura, - pruritus, conjunctivitis, angioedema, hypotension or shock. If moderate to - severe reaction (e.g. thrombocytopenia, hypotension), hospitalization or lifethreatening event: Discontinue - treatment. If mild reaction (e.g. rash, dizziness, - fever): Continue to monitor patient closely with a low threshold for discontinuing treatment. A flu-like - syndrome appears to be the most common side effect - profile leading to discontinuation of the 3HP regimen. + * Hypersensitivity reaction to rifamycins (rifampin, rifabutin, rifapentine): reactions may include a flu-like syndrome (e.g. fever, chills, headaches, dizziness, musculoskeletal pain), thrombocytopenia, shortness of breath or other signs and symptoms including wheezing, acute bronchospasm, urticaria, petechiae, purpura, pruritus, conjunctivitis, angioedema, hypotension or shock. If moderate to severe reaction (e.g. thrombocytopenia, hypotension), hospitalization or life-threatening event: Discontinue treatment. If mild reaction (e.g. rash, dizziness, fever): Continue to monitor patient closely with a low threshold for discontinuing treatment. A flu-like syndrome appears to be the most common side effect profile leading to discontinuation of the 3HP regimen. Rifabutin can rarely cause uveitis.

                  @@ -382,4 +424,5 @@

                  Table 6. LTBI Treatment Drug Adverse Reactions

                  - \ No newline at end of file + + diff --git a/app/src/main/assets/pages/3_treatment_of_latent_tb_infection_(ltbi)__b__monitoring_of_patients_on_treatment_for_ltbi.html b/app/src/main/assets/pages/3_treatment_of_latent_tb_infection_(ltbi)__b__monitoring_of_patients_on_treatment_for_ltbi.html index e4dc050..e773f62 100644 --- a/app/src/main/assets/pages/3_treatment_of_latent_tb_infection_(ltbi)__b__monitoring_of_patients_on_treatment_for_ltbi.html +++ b/app/src/main/assets/pages/3_treatment_of_latent_tb_infection_(ltbi)__b__monitoring_of_patients_on_treatment_for_ltbi.html @@ -15,87 +15,125 @@
                  -

                  For all patients (based on CDC recommendations):

                  -
                    -
                  • Evaluate for active TB disease both before and during treatment of LTBI.
                    • -
                  • Inform the patient or parents or legal guardians about possible adverse effects of the LTBI treatment - regimen and instruct them to seek prompt medical attention when symptoms of possible adverse reaction first - appear; particularly - drug hypersensitivity reactions, rash, hypotension, or signs - of thrombocytopenia (see Table - 6). -
                    • -
                  • Conduct monthly evaluations to assess treatment adherence - and adverse effects, with repeated patient education regarding adverse effects at each visit. -
                    • -
                  • For those on self-administered therapy, never dispense - more than one month of therapy (and no refills). Include - careful questioning about side effects and a brief physical - examination checking for evidence of hepatitis or other side - effects during each visit. -
                    • -
                  • Order baseline hepatic chemistry blood tests (AST or ALT) - for patients with the following specific conditions: HIV infection, liver disorders, postpartum period (≤ 3 - months after - delivery), regular alcohol use, injection drug use, or use of - medications with known possible interactions. (We prefer to - obtain a baseline laboratory chemistry profile including a - hepatic chemistry blood test on all adult patients starting - LTBI therapy.) -
                    • -
                  • In the absence of liver disease or HIV infection, children on - LTBI therapy do not need monthly ALT or AST monitoring. -
                    • -
                  • Conduct blood tests at subsequent clinical encounters for - patients whose baseline testing is abnormal and for others at - risk for liver disease. Discontinue the LTBI treatment regimen if a serum AST concentration is ≥ 5 times the - upper - limit of normal in the absence of symptoms or ≥ 3 times the - upper limit of normal in the presence of symptoms. -
                    • -
                  • In case of a possible severe adverse reaction, discontinue - the LTBI regimen immediately and provide supportive medical care. Conservative management and continuation - of LTBI - therapy under observation can be considered in the presence of mild to moderate adverse events as determined - by - the health care provider. -
                    • -
                  +
                  +
                  +
                  +
                  + +
                  +

                  III. Treatment of Latent TB Infection (LTBI)

                  +
                  +

                  Last Updated October 2025

                  +
                  +
                  +
                  + For all patients (based on CDC recommendations)⌃ +
                  +
                    +
                  • Evaluate for active TB disease both before and during treatment of LTBI.
                    • +
                  • Inform the patient or parents or legal guardians about possible adverse effects of the LTBI treatment + regimen and instruct them to seek prompt medical attention when symptoms of possible adverse reaction first + appear; particularly + drug hypersensitivity reactions, rash, hypotension, or signs + of thrombocytopenia (see Table + 6). +
                    • +
                  • Conduct monthly evaluations to assess treatment adherence + and adverse effects, with repeated patient education regarding adverse effects at each visit. +
                    • +
                  • For those on self-administered therapy, never dispense + more than one month of therapy (and no refills). Include + careful questioning about side effects and a brief physical + examination checking for evidence of hepatitis or other side + effects during each visit. +
                    • +
                  • Order baseline hepatic chemistry blood tests (AST or ALT) + for patients with the following specific conditions: HIV infection, liver disorders, postpartum period (≤ 3 + months after + delivery), regular alcohol use, injection drug use, or use of + medications with known possible interactions. (We prefer to + obtain a baseline laboratory chemistry profile including a + hepatic chemistry blood test on all adult patients starting + LTBI therapy.) +
                    • +
                  • In the absence of liver disease or HIV infection, children on + LTBI therapy do not need monthly ALT or AST monitoring. +
                    • +
                  • Conduct blood tests at subsequent clinical encounters for + patients whose baseline testing is abnormal and for others at + risk for liver disease. Discontinue the LTBI treatment regimen if a serum AST concentration is ≥ 5 times the + upper + limit of normal in the absence of symptoms or ≥ 3 times the + upper limit of normal in the presence of symptoms. +
                    • +
                  • In case of a possible severe adverse reaction, discontinue + the LTBI regimen immediately and provide supportive medical care. Conservative management and continuation + of LTBI + therapy under observation can be considered in the presence of mild to moderate adverse events as determined + by + the health care provider. +
                    • +
                  +
                  + -

                  Pyridoxine (Vitamin B6) should be used (25-50 mg/day) with INH - for persons with conditions in which neuropathy is common (e.g., - HIV, diabetes, alcoholism, malnutrition) as well as pregnant women and persons with a seizure disorder to - prevent isoniazidassociated neuropathy. It should be given to all HIV-infected - persons, all children, and women who are breastfeeding. For - healthy individuals on a normal diet, pyridoxine is optional. However, we prefer to give pyridoxine to all - patients on INH. Pyridoxine (at 25 mg per day) is also recommended for children on INH.

                  + Indications for regular monthly monitoring of LFTs⌃ +
                  +
                    +
                  • Abnormal ALT (or AST) at baseline
                    • +
                  • HIV infection
                    • +
                  • Pregnancy
                    • +
                  • First three months postpartum
                    • +
                  • Chronic liver disease (including hepatitis C virus [HCV] infection)
                    • +
                  • Regular alcohol use
                    • +
                  • Injection drug use
                    • +
                  • Patients on other drugs which are potentially hepatotoxic
                    • +
                  • Advanced age
                    • +
                  +
                  + + Medication should be discontinued, and patient evaluated if:⌃ +
                  +
                    +
                  • Transaminase levels (i.e., ALT or AST) > 3 times upper limit of + normal in the presence of symptoms of adverse events +
                    • +
                  • Transaminase levels (i.e., ALT or AST) > 5 times upper limit of + normal in an asymptomatic patient +
                    • +
                  +
                  + + Pills + +

                  Pyridoxine (Vitamin B6) should be used (25-50 mg/day) with INH for persons with conditions in + which neuropathy is common (e.g., HIV, diabetes, alcohol use disorder, malnutrition) as well as pregnant women and persons with a seizure disorder to + prevent INH-associated neuropathy. Pyridoxine should be given to all persons living with HIV, all children, and women who are breastfeeding. For healthy + individuals on a normal diet, pyridoxine is optional. However, we prefer to give pyridoxine to all patients on INH. Pyridoxine (at 25 mg per day) is also recommended for children on INH.

                  + diff --git a/app/src/main/assets/pages/3_treatment_of_latent_tb_infection_(ltbi)__c__contacts_of_mdr_tb_cases.html b/app/src/main/assets/pages/3_treatment_of_latent_tb_infection_(ltbi)__c__contacts_of_mdr_tb_cases.html index 73e3b5e..fce91af 100644 --- a/app/src/main/assets/pages/3_treatment_of_latent_tb_infection_(ltbi)__c__contacts_of_mdr_tb_cases.html +++ b/app/src/main/assets/pages/3_treatment_of_latent_tb_infection_(ltbi)__c__contacts_of_mdr_tb_cases.html @@ -15,51 +15,68 @@
                  - -

                  There are no results from randomized controlled trials to guide - therapy for persons with LTBI thought to be infected with MDRTB strains - (although several studies are ongoing and such data should be available in the future). - Several studies are ongoing which should provide - more guidance in the future. In deciding how to treat persons - with LTBI which may be due to infection with an MDR-TB strain, - the following four questions should be considered. - A TB specialist should be consulted in the management of contacts to MDR-TB cases. +

                  +
                  +
                  +
                  + +
                  +

                  III. Treatment of Latent TB Infection (LTBI)

                  +
                  +

                  Last Updated October 2025

                  +
                  +
                  +
                  +

                  + Based on data from two randomized controlled trials (prior to the publications of these studies), the World Health Organization (WHO) published updated recommendations + in September 2024 on preventive treatment among contacts exposed to multidrug- or rifampin-resistant TB (https://www.who.int/publications/i/item/9789240096196). + These studies include TB-CHAMP carried out in South Africa and VQUIN carried out in Vietnam. Treatment with 6 months of daily levofloxacin is now recommended by WHO + for those with LTBI who were exposed to a drug resistant TB case. In December 2024, the TB-CHAMP and VQUIN studies were published in the New England Journal of + Medicine (391:2315-2326 and 391:2304-2314). In both studies, preventive treatment with levofloxacin led to a lower incidence of TB than placebo among those who were contacts to MDR-TB index cases but the differences did not reach statistical significance. In a meta-analysis which included + both the TB-CHAMP and VQUIN studies (NEJM Evid. 2025; 4:EVIDoa2400190), levofloxacin use for preventive therapy was associated with a 60% relative reduction in + TB incidence among adult and child household MDR-TB contacts, but with an increased risk of musculoskeletal adverse events. A TB specialist should + be consulted in the management of contacts to rifampin-resistant and MDR-TB cases. +

                  +

                  + In deciding how to treat persons with LTBI which may be due to infection with a rifampin-resistant or MDR-TB strain, the following four questions should be considered.

                  -
                    -
                  • - How likely is it that a patient is newly TB infected? A patient - with a documented positive prior TST (or another diagnostic - test such as an IGRA) is much less likely to be newly infected. -
                    • + How likely is it that a patient is newly TB infected?⌃ +
                    +

                    A patient with a documented positive prior TST (or another diagnostic + test such as an IGRA) is much less likely to be newly infected.

                    +
                    -
                  • How likely is it that the patient is infected with an MDR-TB - strain? An infant with a positive diagnostic test for LTBI - (TST or IGRA) whose parent has active MDR-TB is highly - likely to be infected with MDR-TB. In contrast, a health care - worker with a positive TST and no known source case may - have a low probability of being MDR-TB infected. -
                    • + How likely is it that the patient is infected with an MDR-TB + strain?⌃ +
                    +

                    An infant with a positive diagnostic test for LTBI + (TST or IGRA) whose parent has active MDR-TB is highly + likely to be infected with MDR-TB. In contrast, a health care + worker with a positive TST and no known source case may + have a low probability of being MDR-TB infected.

                    +
                    -
                  • How likely is the patient to develop active TB? Those at highest risk include persons living with HIV - or otherwise immunocompromised and children < 2 years of age. -
                    • + How likely is the patient to develop active TB?⌃ +
                    +

                    Those at highest risk include persons living with HIV + or otherwise immunocompromised and children < 2 years of age.

                    +
                    -
                  • What is the drug-susceptibility pattern of the source patient’s isolate? Treatment of LTBI must be - tailored to the - susceptibility pattern of the source patient’s isolate. When - the source patient is known to have isoniazid-resistant TB, - rifampin may be used for treatment of LTBI. As noted above, - there are no current evidence-based guidelines for the - treatment of LTBI when an individual is thought to be infected with an MDR-TB strain. In some cases of - MDR-TB or - XDR-TB, no LTBI regimen is available. -
                    • -
                  + What is the drug-susceptibility pattern of the source patient’s isolate?⌃ +
                  +

                  + Treatment of LTBI should be tailored to the susceptibility pattern of the source patient’s isolate. When the source patient is known to have isoniazid-resistant TB, + rifampin may be used for treatment of LTBI. For those with MDR-TB or rifampin resistant TB with fluoroquinolone susceptibility, levofloxacin for 6 months is now included + in WHO guidelines. Again, a TB specialist should be consulted for the management and treatment of LTBI when an individual is thought to be infected with a rifampin-resistant or MDR strain. +

                  +
                  +
                  + diff --git a/app/src/main/assets/pages/4_laboratory_diagnosis_of_active_tuberculosis.html b/app/src/main/assets/pages/4_laboratory_diagnosis_of_active_tuberculosis.html index 3f39c46..15d7feb 100644 --- a/app/src/main/assets/pages/4_laboratory_diagnosis_of_active_tuberculosis.html +++ b/app/src/main/assets/pages/4_laboratory_diagnosis_of_active_tuberculosis.html @@ -15,8 +15,21 @@
                  -

                  List of sub chapters

                  -
                    +
                    +
                    +
                    +
                    + +
                    +

                    IV. Laboratory Diagnosis of Active Tuberculosis

                    +
                    +

                    Last Updated October 2025

                    +
                    +
                    +
                    + +

                    List of sub chapters

                    +
                    • Considerations
                    • Selected Diagnostic Test Characteristics
                      • diff --git a/app/src/main/assets/pages/4_laboratory_diagnosis_of_active_tuberculosis__a__considerations.html b/app/src/main/assets/pages/4_laboratory_diagnosis_of_active_tuberculosis__a__considerations.html index e8640ae..e2ee3c2 100644 --- a/app/src/main/assets/pages/4_laboratory_diagnosis_of_active_tuberculosis__a__considerations.html +++ b/app/src/main/assets/pages/4_laboratory_diagnosis_of_active_tuberculosis__a__considerations.html @@ -15,44 +15,39 @@
                      -
                        -
                      • - Active TB diagnosis is usually pursued by mycobacterial acid - -fast bacilli smear (“AFB smear”), mycobacterial culture (“AFB - culture”), nucleic acid amplification tests, radiological exam, - and histopathology. -
                        • - -
                      • - Phenotypic drug-susceptibility testing is optimal for patient - care and genotyping is paramount for tuberculosis control. - Both tests require an isolate from a positive culture. Thus, - adequate samples for mycobacterial culture should be obtained whenever possible. -
                        • - -
                      • - Diagnostic samples can be collected after TB treatment initiation among patients with life-threatening - disease or other - compelling indications for immediate TB treatment (Figure - 1). -
                        • - -
                      • - TST and/or IGRA are negative in 10-30% of patients with - active TB. Thus, a negative TST and/or IGRA do not rule - out active TB. -
                        • -
                      • - The sensitivity of each test (smear, culture, and nucleic acid - amplification) differs by sample source (e.g., sputum vs. cerebrospinal fluid). -
                        • -
                      • - ATS/CDC/IDSA guidelines for Diagnosis of Tuberculosis in - Adults and Children are a comprehensive source for laboratory tests for TB diagnosis [Lewinsohn et al. - Clinical Infectious Diseases, 2017]. -
                        • - -
                      +
                      +
                      +
                      +
                      + +
                      +

                      IV. Laboratory Diagnosis of Active Tuberculosis

                      +
                      +

                      Last Updated October 2025

                      +
                      +
                      +
                      +

                      + Active TB disease diagnosis is usually pursued by mycobacterial acid -fast bacilli smear (“AFB smear”), mycobacterial culture (“AFB culture”), nucleic acid amplification tests (e.g., Xpert MTB/RIF), radiological exam, and histopathology.

                      + + + +

                      + Phenotypic drug-susceptibility testing (DST) is optimal for patient care and genotyping is paramount for tuberculosis prevention and control. Both DST and genotyping require recovery of an M. tuberculosis isolate from a positive culture. Thus, adequate samples for mycobacterial culture should be obtained whenever possible.

                      + +

                      + Diagnostic samples can be collected after TB treatment initiation among patients with life-threatening disease or other compelling indications for immediate TB treatment (Figure 1). +

                      + +

                      + TST and/or IGRA are negative in 10-30% of patients with active TB. Thus, a negative TST and/or IGRA do not rule out active TB. +

                      +

                      + The sensitivity of each test (smear, culture, and nucleic acid amplification) differs by sample source (e.g., sputum vs. cerebrospinal fluid). +

                      +

                      + ATS/CDC/IDSA guidelines for Diagnosis of Tuberculosis in Adults and Children are a comprehensive source for laboratory tests for TB diagnosis [Lewinsohn et al. Clinical Infectious Diseases, 2017]. +

                      diff --git a/app/src/main/assets/pages/4_laboratory_diagnosis_of_active_tuberculosis__b__selected_diagnostic_test_characteristics.html b/app/src/main/assets/pages/4_laboratory_diagnosis_of_active_tuberculosis__b__selected_diagnostic_test_characteristics.html index 4c46e53..6b372b0 100644 --- a/app/src/main/assets/pages/4_laboratory_diagnosis_of_active_tuberculosis__b__selected_diagnostic_test_characteristics.html +++ b/app/src/main/assets/pages/4_laboratory_diagnosis_of_active_tuberculosis__b__selected_diagnostic_test_characteristics.html @@ -15,20 +15,38 @@
                      +
                      +
                      +
                      +
                      + +
                      +

                      IV. Laboratory Diagnosis of Active Tuberculosis

                      +
                      +

                      Last Updated October 2025

                      +
                      +
                      +
                      +

                      + Below are some selected Diagnosis Test Characteristics: +

                      -
                        -
                      • - AFB smear -
                          -
                        • Turnaround time is usually < 1 day.
                          • -
                        • AFB positive smears are not specific for Mycobacterium + Selected Diagnosis Test + + AFB smear⌃ +
                          +
                            +
                          • Turnaround time is usually < 1 day.
                            • +
                          • AFB positive smears are not specific for Mycobacterium tuberculosis. Non-tuberculous mycobacteria can also lead to positive AFB smears.
                          -
                          • -
                        • AFB culture +
                      + + AFB culture⌃ +
                      • Most laboratories use both solid and liquid culture media.
                      • Growth can be detected as late as 8 weeks in either media.
                        • @@ -38,8 +56,10 @@
                      • Positive cultures are required for phenotypic drugsusceptibility testing and genotyping.
                      - -
                    • Nucleic acid amplification test (NAAT) +
                      • + + Nucleic acid amplification test (NAAT)⌃ +
                      • Turnaround time is usually < 1 day if the laboratory is able to run the test frequently. @@ -47,9 +67,8 @@
                      • Several FDA and non-FDA approved NAATs are available and performance characteristics are variable.
                        • -
                      • Cepheid Xpert MTB/RIF (“Xpert MTB/RIF”) and Hologic - Amplified Mycobacteria Tuberculosis Direct (“MTD”) - NAATs are endorsed by ATS/IDSA/CDC guidelines. +
                      • + Xpert MTB/RIF (Cepheid) and other NAATs are endorsed by the ATS/IDSA/CDC guidelines and FDA approved.
                      • A positive AFB smear with negative Xpert MTB/RIF or MTD NAAT usually indicates presence of non-tuberculous @@ -57,9 +76,10 @@
                      • Xpert MTB/RIF also tests for genotypic evidence of rifampin susceptibility.
                      - +
                      -
                    • Histopathology + Histopathology⌃ +
                      • Necrotizing granulomas in the appropriate clinical scenario should prompt strong consideration for TB. @@ -71,13 +91,12 @@ prompt concern for inadequate sampling.
                      - -
                      • -
                    +
            + diff --git a/app/src/main/assets/pages/4_laboratory_diagnosis_of_active_tuberculosis__c__laboratory_diagnosis_of_pulmonary_tuberculosis.html b/app/src/main/assets/pages/4_laboratory_diagnosis_of_active_tuberculosis__c__laboratory_diagnosis_of_pulmonary_tuberculosis.html index e9f4d9a..ea2ec0f 100644 --- a/app/src/main/assets/pages/4_laboratory_diagnosis_of_active_tuberculosis__c__laboratory_diagnosis_of_pulmonary_tuberculosis.html +++ b/app/src/main/assets/pages/4_laboratory_diagnosis_of_active_tuberculosis__c__laboratory_diagnosis_of_pulmonary_tuberculosis.html @@ -15,54 +15,71 @@
            +
            +
            +
            +
            + +
            +

            IV. Laboratory Diagnosis of Active Tuberculosis

            +
            +

            Last Updated October 2025

            +
            +
            +
            -
              -
            • Immunocompromised patients are less likely to have typical - CXR findings. A normal CXR does not rule out active pulmonary TB.
              • - -
            • A minimum of two AFB smears is generally recommended - for persons with suspected pulmonary TB. The overall sensitivity of AFB smear for pulmonary TB is 50% to - 70%, and the sensitivity is reduced among immunosuppressed and pediatric patients. -
              • -
            • First morning sputum specimens have increased sensitivity - and at least one first morning specimen should be obtained. -
              • -
            • The sensitivity of ATS/IDSA/CDC endorsed NAATs for +

              Immunocompromised patients are less likely to have typical CXR findings (i.e., upper lobe infiltrates which may cavitate). A normal CXR does not rule out active pulmonary TB, especially in a person living with HIV.

              + +

              + A minimum of two AFB smears is generally recommended for persons with presumed pulmonary TB. The overall sensitivity of AFB smear for pulmonary TB is 50% to 70%, and the sensitivity is reduced among immunosuppressed and pediatric patients. +

              + +

              First morning sputum specimens have increased sensitivity + and at least one first morning specimen should be obtained.

              + +

              The sensitivity of ATS/IDSA/CDC endorsed NAATs for smear-negative and smear-positive TB are approximately 67% and 96% respectively. A negative NAAT performed on a smear-negative sample does not rule out TB, whereas a negative NAAT performed on a smear-positive sample usually indicates presence of non-tuberculous - mycobacteria. -

              • -
            • For patients with suspected pulmonary TB who are unable - to produce good quality sputum (defined as > 3 ml of sputum), consider obtaining induced sputum - sample (using 3% - NaCl aerosol) for smear, culture, and NAAT samples. -
              • -
            • Consider obtaining bronchoscopy with transbronchial biopsy for smear, culture, NAAT, and histopathology: a) - for patients with suspected pulmonary TB when sputum induction - fails to produce good quality samples; b) when empiric TB - treatment is unacceptable (e.g., high-risk for MDR TB); and/ - or c) when bronchoscopy is indicated to investigate alternative diagnosis (e.g., lung cancer). -
              • -
            • Bronchoscopy is an aerosol-generating procedure, and - infection control measures for airborne pathogens should - be observed.
              • -
            • Consider obtaining post-bronchoscopy sputum sample for - smear and culture. -
              • -
            • Children are more likely to have paucibacilliary disease and - are often unable to produce good quality sputum specimens. - However, clinicians should pursue microbiological TB diagnosis when feasible. Gastric aspirate when - appropriately - performed has yield > 50%. Instruct patients to fast overnight. Commensal non-tuberculous mycobacteria are - present in the GI tract and a positive AFB smear should be interpreted with caution. - (https://www.currytbcenter.ucsf.edu/products/pediatrictuberculosis-guide-gastric-aspirate-procedure) -
              • -
            + mycobacteria.

            + +

            + For persons with presumed pulmonary TB who are unable to produce good quality sputum (defined as > 3 ml of sputum), consider obtaining induced sputum sample (using 3% NaCl aerosol) for smear, culture, and NAAT samples. +

            + + medal + + Consider obtaining bronchoscopy with transbronchial biopsy for smear, culture, NAAT, and histopathology: ⌃ + +
            +
              +
            • a) for patients with presumed pulmonary TB who are unable to produce a sputum and sputum induction fails to produce good quality samples;
              • +
            • b) when empiric TB treatment is unacceptable (e.g., high-risk for MDR TB);
              • +
            • and/or c) when bronchoscopy is indicated to investigate alternative diagnosis (e.g., lung cancer).
              • +
            +
            + +

            + Bronchoscopy is an aerosol-generating procedure, and infection control and prevention measures for airborne pathogens should be observed. +

            + +

            Consider obtaining post-bronchoscopy sputum sample for + smear, culture, and NAAT

            + +

            + Children are more likely to have paucibacillary disease and are often unable to produce good quality + sputum specimens. However, clinicians should pursue microbiological TB diagnosis when feasible. Stool + for AFB culture and gastric aspirate when appropriately performed has a yield of > 50%. Instruct + patients to fast overnight prior to having the gastric aspirate performed. Commensal non-tuberculous + mycobacteria are present in the GI tract and a positive AFB smear of a gastric aspirate should be + interpreted with caution. (https://www.currytbcenter.ucsf.edu/products/view/pediatric-tuberculosis-guide-gastric-aspirate-ga-procedure). +

            +
            + diff --git a/app/src/main/assets/pages/4_laboratory_diagnosis_of_active_tuberculosis__d__laboratory_diagnosis_of_extrapulmary_tuberculosis.html b/app/src/main/assets/pages/4_laboratory_diagnosis_of_active_tuberculosis__d__laboratory_diagnosis_of_extrapulmary_tuberculosis.html index 1f7f285..21ad0a8 100644 --- a/app/src/main/assets/pages/4_laboratory_diagnosis_of_active_tuberculosis__d__laboratory_diagnosis_of_extrapulmary_tuberculosis.html +++ b/app/src/main/assets/pages/4_laboratory_diagnosis_of_active_tuberculosis__d__laboratory_diagnosis_of_extrapulmary_tuberculosis.html @@ -15,46 +15,48 @@
            - - -
              -
            • Patients with suspected extrapulmonary TB should always - be evaluated for concomitant pulmonary TB with at least - CXR and sputum smear and culture. -
              • -
            • Tissue biopsies are aerosol-generating procedures, and - infection control measures for airborne pathogens should - be observed in cases of suspected TB. -
              • -
            • Sensitivity of smear, culture, and NAAT tests are generally +
              +
              +
              +
              + +
              +

              IV. Laboratory Diagnosis of Active Tuberculosis

              +
              +

              Last Updated October 2025

              +
              +
              +
              +

              Patients with suspected extrapulmonary TB should always be evaluated for concomitant pulmonary TB with at least CXR and sputum smear, culture, and NAAT. +

              +

              + Tissue biopsies are aerosol-generating procedures, and infection control and prevention measures for airborne pathogens should be observed in cases of suspected TB. +

              +

              Sensitivity of smear, culture, and NAAT tests are generally reduced for extrapulmonary samples compared to sputum samples. -

              • -
            • NAATs can be performed in extrapulmonary samples. However, NAATs are not FDA-approved for extrapulmonary - samples, and negative results should be interpreted with caution. Extra-pulmonary samples are more likely to - contain PCR inhibitors, and clinicians should discuss test validity - (i.e., positive-control results) with laboratory. -
              • -
            • Diagnostic tests have low sensitivity for central nervous +

              +

              NAATs can be performed in extrapulmonary samples. However, NAATs are not FDA-approved for extrapulmonary samples, and negative results should be interpreted with caution. Extra-pulmonary samples are more likely to contain PCR inhibitors, and clinicians should discuss test validity (i.e., positive-control results) with their laboratory. +

              +

              Diagnostic tests have low sensitivity for central nervous system TB. Cerebrospinal fluid AFB smear sensitivity is very low (< 5%), and culture and Xpert MTB/RIF both have sensitivity < 70%. -

              • -
            • Pleural tissue histopathological exam sensitivity is > 70%, +

              +

              Pleural tissue histopathological exam sensitivity is > 70%, whereas pleural fluid and pleural tissue smear sensitivity are < 10% and < 40%, respectively. Pleural fluid and pleural tissue culture sensitivity are < 70% -

              • -
            • Fine needle aspiration (FNA) is as an appropriate diagnostic +

              +

              Fine needle aspiration (FNA) is as an appropriate diagnostic test for suspected TB lymphadenitis. However, excisional biopsy has higher yield and should be pursued when FNA results are negative and suspicion for TB remains high. -

              • -
            • Consider obtaining adenosine deaminase (ADA) pleural, pericardial, peritoneal, or meningeal fluid in +

              +

              Consider obtaining adenosine deaminase (ADA) pleural, pericardial, peritoneal, or meningeal fluid in addition to smear, culture, and NAAT. However, ADA result should be interpreted with caution as sensitivity and specificity are highly influenced by cut-off values and anatomical sample source. -

              • -
            +

            diff --git a/app/src/main/assets/pages/4_laboratory_diagnosis_of_active_tuberculosis__e__rapid_molecular_drug_susceptibility_tests_(dst).html b/app/src/main/assets/pages/4_laboratory_diagnosis_of_active_tuberculosis__e__rapid_molecular_drug_susceptibility_tests_(dst).html index fb59def..382e2e9 100644 --- a/app/src/main/assets/pages/4_laboratory_diagnosis_of_active_tuberculosis__e__rapid_molecular_drug_susceptibility_tests_(dst).html +++ b/app/src/main/assets/pages/4_laboratory_diagnosis_of_active_tuberculosis__e__rapid_molecular_drug_susceptibility_tests_(dst).html @@ -15,25 +15,28 @@
            -
              -
            • +
              +
              +
              +
              + +
              +

              IV. Laboratory Diagnosis of Active Tuberculosis

              +
              +

              Last Updated October 2025

              +
              +
              +
              +

              All patients with culture-confirmed TB should have phenotypic DST performed. However, these tests are limited by a long turnaround time. -

              • -
            • Several genotypic DST are available, and the Xpert MTB/RIF - is the mostly commonly used in the U.S. with turnaround - time < 1 day. -
              • -
            -

            Xpert MTB/RIF sensitivity and specificity for rifampin-resistant - TB is > 92% and 99%, respectively. However, given the low incidence of rifampin resistance in the U.S., Xpert - MTB/RIF positive - predictive value is low. Pre-test probability for rifampin resistance is increased among patients with prior TB - treatment and - patients with prolonged stay in high burden TB countries. A test - result indicating rifampin resistance should prompt consultation - with a TB expert (see Appendix).

            +

            +

            + Several genotypic DST are available, and the Xpert MTB/RIF (which includes a genotypic test for rifampin resistance) is the mostly commonly used in the U.S. with turnaround time < 1 day. +

            +

            Xpert MTB/RIF sensitivity and specificity for rifampin-resistant TB is > 92% and 99%, respectively. However, given the low incidence of rifampin resistance in the U.S., Xpert MTB/RIF positive predictive value is low. Pre-test probability for rifampin resistance is increased among persons with prior TB treatment and persons with prolonged stay in high burden TB countries. A test result indicating rifampin resistance should prompt consultation with a TB expert (see Appendix).

            +

            diff --git a/app/src/main/assets/pages/5_treatment_of_current_(active)_disease_therapy.html b/app/src/main/assets/pages/5_treatment_of_current_(active)_disease_therapy.html index de60879..174c595 100644 --- a/app/src/main/assets/pages/5_treatment_of_current_(active)_disease_therapy.html +++ b/app/src/main/assets/pages/5_treatment_of_current_(active)_disease_therapy.html @@ -14,22 +14,35 @@
            -

            List of Subchapters

            +
            +
            +
            +
            + +
            +

            V. Treatment of Current (Active) Disease Therapy

            +
            +

            Last Updated October 2025

            +
            +
            +
            + +

            List of Subchapters

            -
              + -

              List of charts

              -
                +

                List of charts

                + -

                List of Figures

                -
                  +

                  List of Figures

                  + diff --git a/app/src/main/assets/pages/5_treatment_of_current_(active)_disease_therapy__a__considerations.html b/app/src/main/assets/pages/5_treatment_of_current_(active)_disease_therapy__a__considerations.html index 56be1f6..84bd61a 100644 --- a/app/src/main/assets/pages/5_treatment_of_current_(active)_disease_therapy__a__considerations.html +++ b/app/src/main/assets/pages/5_treatment_of_current_(active)_disease_therapy__a__considerations.html @@ -14,6 +14,19 @@
                  +
                  +
                  +
                  +
                  + +
                  +

                  V. Treatment of Current (Active) Disease Therapy

                  +
                  +

                  Last Updated October 2025

                  +
                  +
                  +
                  +
                  1. The provider (or public health program) is responsible for prescribing an appropriate regimen @@ -24,13 +37,13 @@ with (or assume responsibility for if the clinician prefers) managing the TB treatment. The TB program can also provide access to TB experts throughout the state. Contact information for TB coordinators in each - county is found in the Appendix and at the Appendix and at  the Georgia DPH website
                  2. The decision to initiate treatment for active TB is often (appropriately) made prior to the confirmation - of the diag- nosis. Numerous factors are considered in making this decision and are outlined in Figure 1.
                    3. + of the diagnosis. Numerous factors are considered in making this decision and are outlined in Figure 1.
                  3. Early or immediate reporting to the county health department or state TB program is indicated for:
                    4. @@ -38,13 +51,13 @@
                  4. Suspected or documented drug resistance
                  5. Patients with molecular test indicating rifampin resistance
                  6. Patients with prior treatment for active TB
                    7. -
                  7. Patients failing treatment for active TB
                    8. -
                  8. Life-threatening illness from suspected (or documented) active TB (i.e., meningitis or ICU admission) +
                  9. Patients who did not respond to treatment for active TB disease
                    10. +
                  10. Life-threatening illness from suspected (or documented) active TB disease (i.e., meningitis or ICU admission)
              • Directly Observed Therapy (DOT) to ensure adherence and treatment completion is the standard of care - for all patients with active TB. DOT is managed by the county public health department. A variety of approaches to DOT, including Video-DOT, are employed by our TB program. The Georgia DPH TB Control Program + for all patients with active TB. DOT is managed by the county public health department. A variety of approaches to DOT, including Video DOT (vDOT), are employed by our TB program. The Georgia DPH TB Control Program provides patient-centered care for all patients. Treatment is tailored and supervised based on each patient’s clinical and social circumstances. TB treatment is most successful within a comprehensive framework that @@ -70,10 +83,7 @@ examination is far more important than monitoring chest radiographs.
                • -
              • If a patient’s sputum cultures remain positive beyond 2 months of therapy, the possibility of drug-resistant - disease, malabsorption, or patient non-adherence to taking medications as prescribed should be considered. - Drug - susceptibility testing studies should be repeated, and care should be re- viewed with experts. +
              • If a patient’s sputum cultures remain positive for M. tuberculosis beyond 2 months of therapy, the possibility of drug-resistant disease, malabsorption, or patient non-adherence to taking medications as prescribed should be considered. Drug susceptibility testing studies should be repeated, and care should be reviewed with experts.
              • Adjust weight-based doses as weight changes.
                • diff --git a/app/src/main/assets/pages/5_treatment_of_current_(active)_disease_therapy__b__standard_therapy_for_current_(active)_disease.html b/app/src/main/assets/pages/5_treatment_of_current_(active)_disease_therapy__b__standard_therapy_for_current_(active)_disease.html index ce369a8..f93f968 100644 --- a/app/src/main/assets/pages/5_treatment_of_current_(active)_disease_therapy__b__standard_therapy_for_current_(active)_disease.html +++ b/app/src/main/assets/pages/5_treatment_of_current_(active)_disease_therapy__b__standard_therapy_for_current_(active)_disease.html @@ -13,36 +13,43 @@
                +
                +
                +
                +
                + +
                +

                V. Treatment of Current (Active) Disease Therapy

                +
                +

                Last Updated October 2025

                +
                +
                +
                +
                  -
                1. Initiate therapy with a 4-drug regimen as shown in (Table 7 ). -

                  Any patient who is started on treatment for suspected or proven active TB (even while still - in - the hospital) should be reported to local public health authorities at the time treatment is - started.

                  -

                  Therapy consists of an initiation phase and a continuation phase.

                  -

                  The initiation phase generally consists of a 4-drug regimen given daily or 5 times per week per DOT. An - option for twice weekly therapy by DOT after the initial 2 weeks of daily therapy (“Denver regimen”) - also - exists but is only rarely appropriate. This "Denver regimen" option should NOT be used for persons living with HIV infection, - cavitary pulmonary TB, disseminated TB, vertebral TB or for patients who have co-morbid medical - conditions - such as diabetes mellitus, end-stage renal disease, or liver disease.

                  -

                  The initiation phase is followed by a continuation phase. For drug susceptible disease, this can consist - of - daily, 5 times per week or thrice weekly by DOT (see Table 7 ). For patients with HIV co-infection, in - the - continuation phase, twice weekly therapy is contraindicated because of increased risk of relapse with - rifampin-resistant disease; in such cases therapy should be given daily (or 5 times per week) or thrice - weekly by DOT. In general, daily therapy is preferred throughout for patients with HIV co-infection or - other - immune-compromising conditions. See Figure 1.

                  -

                  See Tables 8 and 9, 10, 11, 12 for dosing recommendations for adults and children.

                  +
                2. + Initiate therapy with a 4-drug regimen as shown in (Table 7 )⌃ +
                  +
                    +
                  • + Any patient who is started on treatment for suspected or proven active TB disease (even while still in the hospital) should be reported to local public health authorities at the time treatment is started. +
                  • Therapy consists of an initiation phase and a continuation phase.
                    • +
                  • The initiation phase for presumed on confirmed drug-susceptible active TB disease generally consists of a 4-drug regimen given daily or 5 times per week per DOT. An option for twice weekly therapy by DOT after the initial 2 weeks of daily therapy (“Denver regimen”) is not recommended by the Georgia TB Program for any persons diagnosed with active TB disease and should never be used for persons living with HIV infection, cavitary pulmonary TB, disseminated TB, vertebral TB or for patients who have co-morbid medical conditions such as diabetes mellitus, end-stage renal disease, or liver disease.
                    • +
                  • The initiation phase is followed by a continuation phase. For drug susceptible disease, this can consist + of + daily, 5 times per week or thrice weekly by DOT (see Table 7 ). For patients with HIV co-infection, in + the + continuation phase, twice weekly therapy is contraindicated because of increased risk of relapse with + rifampin-resistant disease; in such cases therapy should be given daily (or 5 times per week) or thrice + weekly by DOT. In general, daily therapy is preferred throughout for patients with HIV co-infection or + other + immune-compromising conditions. See Figure 1.
                    • +
                  • See Tables 8 and 9, 10, 11, 12 for dosing recommendations for adults and children.
                    • + +
                  +
                  3. - -
                3. For patients with pulmonary tuberculosis, sputum specimens should be obtained at a minimum on a monthly - basis - until two consecutive specimens are culture negative (some obtain monthly specimens throughout the course of - therapy). As discussed above, the 2-month culture is a critical data-point. +
                4. For patients with pulmonary TB, sputum specimens should be obtained at a minimum on a monthly basis until two consecutive specimens are culture negative (some obtain monthly specimens throughout the course of therapy). As discussed above, the 2-month culture is a critical data-point.
                5. Twice-weekly therapy is not recommended for use in the continuation phase by us and is contraindicated for @@ -50,7 +57,7 @@
                  6. -
                6. Rifampin has many drug-drug interactions and may accelerate clearance of drugs metabolized by the liver +
                7. Rifampin (RIF) has many drug-drug interactions and may accelerate clearance of drugs metabolized by the liver including methadone, coumadin, glucocorticoids, estrogens, oral hypoglycemic agents, anticonvulsants, fluconazole, voriconazole, itraconazole, cyclosporin, and protease inhibitors. Rifabutin can be used as a first @@ -64,7 +71,6 @@
              -
            • Dose-counting: Although TB treatment regimens are generally described in terms of “months” of treatment, it is important that each patient receives an adequate number of doses. Thus, treatment completion is defined by @@ -72,33 +78,38 @@ regimen is listed in Table 7 .
              • -
            • Follow-up after completion of therapy is generally not needed for patients who have had a satisfactory and - prompt bacteriologic response and who have completed observed therapy with a 6- or 9-month INH- and - RIF-containing regimen. Patients should be informed to seek prompt medical evaluation if symptoms reappear. - Many - authorities would continue to follow patients who are HIV-infected or who had drug-resistant isolates.
              • +
            • Follow-up after completion of therapy is generally not needed for patients who have had a satisfactory and prompt bacteriologic response and who have completed observed therapy with a 6- or 9-month INH- and RIF-containing regimen for drug-susceptible TB. Patients should be informed to seek prompt medical evaluation if symptoms reappear.
          -

          -

          Precautions

          + Precautions⌃ +
            -
          • Daily intake of alcohol increases the risk of hepatitis for patients taking INH.
            • +
          • Daily intake of alcohol increases the risk of hepatitis among patients taking INH.
          • Never add a single drug to a failing regimen.
            • -
          • Directly observed therapy (DOT) is the standard of care for administering treatment of - active - TB, and such treatment should be supervised and coordinated by the local health - department. For +
          • Directly observed therapy (DOT) is the standard of care for administering treatment of active TB disease, and such treatment should be supervised and coordinated by the local health department. For any patient on self-administered therapy, dispense only a 1-month supply of medicine at a time.
          -

          -

          On the horizon

          -

          Results of a recent study have been reported that indicate a 4-month treatment regimen of rifapentine, - moxifloxacin, isoniazid, and pyrazinamide was found to be non-inferior compared to the standard 6 month TB - treatment regimen for active drug-susceptible pulmonary TB (N Engl J Med 2021; 384:1705-1718). - This study provides evidence that in the future it may be possible to use shorter TB treatment regimens. - This 4 month regimen is not currently recommended by the Georgia State TB Program. CDC is developing guidelines on the use of this new regimen and further infrastructure development for fluoroquinolone susceptibility testing will also be needed.

          +
          + 4-month Treatment Regimens for Drug-Susceptible TB⌃ +
          +
            +
          • + A 4-month treatment regimen of rifapentine, moxifloxacin, isoniazid, and pyrazinamide was found to be non-inferior compared to the standard 6-month TB treatment regimen for active drug-susceptible pulmonary TB (N Engl J Med 2021; 384:1705-1718). +
            • +
          • + This study provides evidence that in the future it may be possible to use shorter TB treatment regimens. +
            • +
          • + This 4-month regimen is not currently recommended by the Georgia Department of Public Health TB Program. +
            • +
          • + CDC has released interim guidelines on the use of this new 4-month regimen (http://dx.doi.org/10.15585/mmwr.mm7108a1); further infrastructure development for fluoroquinolone susceptibility testing of M. tuberculosis isolates is also needed to implement this new treatment regimen in Georgia and other communities in the U.S. +
            • +
          +
          + diff --git a/app/src/main/assets/pages/5_treatment_of_current_(active)_disease_therapy__c__special_clinical_situations.html b/app/src/main/assets/pages/5_treatment_of_current_(active)_disease_therapy__c__special_clinical_situations.html index 6ced1a0..e5855f9 100644 --- a/app/src/main/assets/pages/5_treatment_of_current_(active)_disease_therapy__c__special_clinical_situations.html +++ b/app/src/main/assets/pages/5_treatment_of_current_(active)_disease_therapy__c__special_clinical_situations.html @@ -14,6 +14,18 @@
          +
          +
          +
          +
          + +
          +

          V. Treatment of Current (Active) Disease Therapy

          +
          +

          Last Updated October 2025

          +
          +
          +

          1. Dosing for TB medications in adults with renal impairment is shown in Table 13 .

            @@ -21,10 +33,15 @@

          2. Therapy for TB in clinical situations for which standard TB therapy may not be tolerated or may be ineffective is shown in Table 14 and Table 15 .

            3. -
          3. There is a new regimen with a proof of concept that TB treatment can be completed in four months. At this time, Georgia Department of Public Health does not have the infrastructure for routine implementation of this treatment regimen. Current obstacles to implementation include:
              -
            • Supply of Rifepentine (cost and access)
              • -
            • Genotypic and phenotypic testing for FQ susceptibility (cost and access).
            -
            4. +
          4. There is a new 4-month TB treatment regimen for the treatment of drug-susceptible active TB disease as noted above. At this time, the Georgia Department of Public Health does not have the infrastructure for routine implementation of this 4-month treatment regimen.
            5. + +
          5. Current obstacles to implementation include:⌃ +
            +
              +
            • Supply of Rifapentine (cost and access)
              • +
            • Genotypic and phenotypic testing for fluoroquinolone (FQ) susceptibility (cost and access).
            +
            +
          @@ -42,54 +59,94 @@
        • Table 15. Clinical Situations when standard therapy cannot be given or is not well-tolerated or may not be effective
        -

        Table 7: Recommended Regimens for Treatment of Adults and Children with Drug Susceptible TB Pulmonary TB

        +

        Table 7: Recommended Regimens for Treatment of Adults and Children with Drug Susceptible TB Pulmonary TB

        -

        Table 8: First-Line TB Drugs: Dosing for Adults (ages 16 and over) Directly Observed Therapy (DOT) is mandatory

        +

        Table 8: First-Line TB Drugs: Fixed/ Weight Based Dose for Adults (ages 16 and over) Directly Observed Therapy (DOT) is mandatory

        - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
        DrugsAdult Dose based on body weight in kilograms (kg)* - Adverse Reactions
        DailyThrice-WeeklyTwice-Weekly
        Isoniazid300 mg900 mg900 mg -
          -
        • Gastrointestinal (GI) upset
          • -
        • Liver enzyme elevation
          • -
        • Hepatitis
          • -
        • Mild effects on central nervous
          • -
        • Drug interactions
          • -
        -
        Rifampin600 mg600 mg600 mg -
          -
        • Orange discoloration of body fluids and secretions
          • -
        • Drug interactions
          • -
        • GI upset
          • -
        • Hepatitis
          • -
        • Bleeding problems
          • -
        • Influenze-like symptoms
          • -
        • Rash
          • -
        • Uveitis (rifabutin only)
          • -
        -
        Rifabutin300 mgNot recommendedNot recommended
        Pyrazinamide**40-55 kg: 1000 mg40-55 kg: 1500 mg40-55 kg: 2000 mg -
          -
        • GI upset
          • -
        • Joint aches
          • -
        • Hepatitis
          • -
        • Rash
          • -
        • Hyperuricemia
          • -
        • Gout (rare)
          • -
        -
        56-75 kg: 1500 mg56-75 kg: 2500 mg56-75 kg: 3000 mg
        76+ kg: 2000 mg76+ kg: 3000 mg76+ kg: 4000 mg
        Ethambutol**40-55 kg: 800 mg40-55 kg: 1200 mg40-55 kg: 1600 mg -
          -
        • Optic neuritis
          • -
        -
        56-75 kg: 1200 mg56-75 kg: 2000 mg56-75 kg: 2400 mg
        76+ kg: 2000 mg76+ kg: 2800 mg76+ kg: 4000 mg
        +
        +
          +
          • +
          • +
          • +
          • +
          • +
        +
        + +
        + + + + + + + + + + + + + + + + + +
        FrequencyDailyThrice-Weekly
        Adult Dose based on body weight in kilograms (kg)*300 mg900 mg
        Adverse Reactions +
          +
        • Gastrointestinal (GI) upset
          • +
        • Liver enzyme elevation
          • +
        • Hepatitis
          • +
        • Mild effects on central nervous
          • +
        • Drug interactions
          • +
        +
        +
        + +
        + + + + + + + + + + + + + + + + + +
        FrequencyDailyThrice-Weekly
        Adult Dose based on body weight in kilograms (kg)*600 mg600 mg
        Adverse Reactions +
          +
        • Orange discoloration of body fluids and secretions
          • +
        • Drug interactions
          • +
        • GI upset
          • +
        • Hepatitis
          • +
        • Bleeding problems
          • +
        • Influenze-like symptoms
          • +
        • Rash
          • +
        • Uveitis (rifabutin only)
          • +
        +
        +
        + +
        + + + + + + + + + + + + + + + + + +
        FrequencyDailyThrice-Weekly
        Adult Dose based on body weight in kilograms (kg)*300 mgNot recommended
        Adverse Reactions +
          +
        • Orange discoloration of body fluids and secretions
          • +
        • Drug interactions
          • +
        • GI upset
          • +
        • Hepatitis
          • +
        • Bleeding problems
          • +
        • Influenze-like symptoms
          • +
        • Rash
          • +
        • Uveitis (rifabutin only)
          • +
        +
        +
        + +
        + + + + + + + + + + + + + + + + + + + + + + + + + +
        FrequencyDailyThrice-Weekly
        Adult Dose based on body weight in kilograms (kg)*40-55 kg: 1000 mg40-55 kg: 1500 mg
        56-75 kg: 2500 mg56-75 kg: 1500 mg
        76+ kg: 3000 mg76+ kg: 4000 mg
        Adverse Reactions +
          +
        • Orange discoloration of body fluids and secretions
          • +
        • Drug interactions
          • +
        • GI upset
          • +
        • Hepatitis
          • +
        • Bleeding problems
          • +
        • Influenze-like symptoms
          • +
        • Rash
          • +
        • Uveitis (rifabutin only)
          • +
        +
        +
        + +
        + + + + + + + + + + + + + + + + + + + + + + + + + +
        FrequencyDailyThrice-Weekly
        Adult Dose based on body weight in kilograms (kg)*40-55 kg: 800 mg40-55 kg: 1200 mg
        56-75 kg: 1200 mg56-75 kg: 2000 mg
        76+ kg: 1600 mg76+ kg: 2400 mg
        Adverse Reactions +
          +
        • Optic neuritis
          • +
        +
        +

        *Formula used to convert pounds to kilograms: Divide pounds by 2.2 to get kilograms.

        Example: Patient weighs 154 pounds ÷ 2.2 = 70 kilograms.

        @@ -247,7 +376,7 @@

        Table 8: First-Line TB Drugs: Dosing for Adults (ages 16 and ove

        -

        Table 9: Pediatric Dosage - Isoniazid in Children (birth to 15 years)

        +

        Table 9: Pediatric Dosage - Isoniazid in Children (birth to 15 years)

        @@ -259,110 +388,110 @@

        Table 9: Pediatric Dosage - Isoniazid in Children (birth to 15 y Child's Weight (lbs) Child's Weight (kg) Daily Dose (mg) 10-15 mg/kg PO - Twice-weekly Dose (mg) 20-30 mg/kg PO + 6 - 10 3 - 4.5 50 - 100mg PO + 11 - 14 5.0 - 6.0 50 - 150mg PO + 14.5 - 18 6.5 – 8.0 100 - 200mg PO + 18.5 - 21.5 8.5 – 9.5 100 - 250mg PO + 22 – 24 10.0 – 11 150 - 300mg PO + 25 - 29 11.5 - 13 150 - 350 mg PO + 29.5 - 32 13.5 - 14.5 200 - 400 mg PO + 33 - 35 15 - 16 200 - 450 mg PO + 36 - 40 16.5 - 18 250 - 500 mg PO + 40.5 - 43 18.5 - 19.5 250 - 550 mg PO + 44 - 48 20 - 21.5 300 - 600 mg PO + 48.5 - 51 22 - 23 300 - 650 mg PO + 52 - 54.5 23.5 - 24.5 300 - 700 mg PO + 55 - 57.5 25 - 26 300 - 750 mg PO + 58 - 62 26.5 - 28 300 - 800 mg PO + 62.5 - 65 28.5 - 29.5 300 - 850 mg PO + 66 + 30 + 300 - 900 mg PO + @@ -375,7 +504,7 @@

        Table 9: Pediatric Dosage - Isoniazid in Children (birth to 15 y

        -

        Table 10. Pediatric Dosages - Rifampin in Children (birth to 15 years)

        +

        Table 10. Pediatric Dosages - Rifampin in Children (birth to 15 years)

        @@ -413,7 +542,7 @@

        Table 10. Pediatric Dosages - Rifampin in Children (birth to 15

        -

        Table 11: Pediatric Dosages - Ethambutol in Children (birth to 15 years)

        +

        Table 11: Pediatric Dosages - Ethambutol in Children (birth to 15 years)

        @@ -476,11 +605,14 @@

        Table 11: Pediatric Dosages - Ethambutol in Children (birth to 1600 mg +

        + The maximum recommendation for ethambutol is 1 g daily. +

        -

        Table 12: Pediatric Dosages - Pyrazinamide in Children (birth to 15 years)

        +

        Table 12: Pediatric Dosages - Pyrazinamide in Children (birth to 15 years)

        Table 12: Pediatric Dosages - Pyrazinamide in Children (birth t Child's Weight (lbs) Child's Weight (kg) Daily Dose (mg) 30-40 mg/kg PO - Twice-weekly Dose (mg) 50-70 mg/kg PO + 13 - 23 6 - 10.5 250 mg - 500 mg + 24 - 26 11 - 12 250 mg - 750 mg + 27 - 31 12.5 - 14 500 mg - 1000 mg + 32 - 41 14.5 - 18.5 500 mg - 1250 mg + 42 - 47 19.0 - 21.5 750 mg - 1250 mg + 48 - 54 22.0 - 24.5 750 mg - 1500 mg + 55 – 63 25 – 28.5 1000 mg - 1750 mg + 64 – 67 29 – 30.5 1000 mg - 2000 mg + 68 – 80 31 – 36.5 1250 mg - 2000 mg + 81 – 93 37 – 42.5 1500 mg - 2000 mg + 94 – 106 43 – 48.5 1750 mg - 2000 mg + 107 + 49 + 2000 mg - 2000 mg +
        -

        Table 13: Antituberculosis Antibiotics in Adult Patients with Renal Impairment

        +

        Table 13: Antituberculosis Antibiotics in Adult Patients with Renal Impairment

        NOTE: Drug adjustments are based on the creatinine clearance (CrCl) which can be estimated as follows:

        [(140-age in yrs)(Ideal body weight in kg) for men (x 0l85 for women)] / [(72) (serum creatinine, mg/dL)]

        @@ -579,69 +711,234 @@

        Table 13: Antituberculosis Antibiotics in Adult Patients with R

        Ideal body weight for women: 45.5 kg + 2.3 kg per inch over 5 feet

        +
        +
          +
          • +
          • +
          • +
          • +
          • +
          • +
          • +
          • +
        +
        + +

        + NOTE: Drug adjustments are based on the creatinine clearance (CrCl) which can be estimated as follows:
        + [(140-age in yrs)(Ideal body weight in kg) for men (x 0l85 for women)] / [(72) (serum creatinine, mg/dL)] + Ideal body weight for men: 50 kg + 2.3 kg per inch over 5 feet + Ideal body weight for women: 45.5 kg + 2.3 kg per inch over 5 feet +

        + +
        - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - + + + + + + + + + + + + + + + + + + +
        DrugUsual Dose (UD) Normal Renal FunctionCrCl 30-90CrCL <30 or HemodialysisPeritoneal Dialysis
        INH300 mg/dayUDUDData currently are not available for patients receiving peritoneal dialysis. Until data - become available, begin with doses recommended for patients receiving hemodialysis and verify - adequacy of dosing using serum concentration monitoring. -
        Rifampin600 mg/dayUDUD
        Ethambutol15-25 mg/kg/dayUD20-25 mg/kg/dose thrice weekly
        Pyrazinamide25 mg/kg d (max 2 gm/day)UD25-35 mg/kg/dose thrice weekly
        Levofloxacin750 mg/dayUD750-1000 mg/dose thrice weekly
        Moxifloxacin400 mg/dayUDUD
        Amikacin15 mg/kg/daily or thrice weeklyUD15 mg/kg/dose thrice weekly
        Linezolid600 mg/dayUDUD
        Usual Dose (UD) Normal Renal Function300 mg/day
        CrCl 30-90UD
        CrCL <30 or HemodialysisUD
        Peritoneal DialysisData currently are not available for patients receiving peritoneal dialysis. Until data + become available, begin with doses recommended for patients receiving hemodialysis and verify + adequacy of dosing using serum concentration monitoring. +
        +
        + +
        + + + + + + + + + + + + + + + + + + + +
        Usual Dose (UD) Normal Renal Function600 mg/day
        CrCl 30-90UD
        CrCL <30 or HemodialysisUD
        Peritoneal DialysisData currently are not available for patients receiving peritoneal dialysis. Until data + become available, begin with doses recommended for patients receiving hemodialysis and verify + adequacy of dosing using serum concentration monitoring. +
        +
        + +
        + + + + + + + + + + + + + + + + + + + +
        Usual Dose (UD) Normal Renal Function15-25 mg/kg/day
        CrCl 30-90UD
        CrCL <30 or Hemodialysis20-25 mg/kg/dose thrice weekly
        Peritoneal DialysisData currently are not available for patients receiving peritoneal dialysis. Until data + become available, begin with doses recommended for patients receiving hemodialysis and verify + adequacy of dosing using serum concentration monitoring. +
        +
        + +
        + + + + + + + + + + + + + + + + + + + +
        Usual Dose (UD) Normal Renal Function25 mg/kg d (max 2 gm/day)
        CrCl 30-90UD
        CrCL <30 or Hemodialysis25-35 mg/kg/dose thrice weekly
        Peritoneal DialysisData currently are not available for patients receiving peritoneal dialysis. Until data + become available, begin with doses recommended for patients receiving hemodialysis and verify + adequacy of dosing using serum concentration monitoring. +
        +
        + +
        + + + + + + + + + + + + + + + + + + + +
        Usual Dose (UD) Normal Renal Function750 mg/day
        CrCl 30-90UD
        CrCL <30 or Hemodialysis750-1000 mg/dose thrice weekly
        Peritoneal DialysisData currently are not available for patients receiving peritoneal dialysis. Until data + become available, begin with doses recommended for patients receiving hemodialysis and verify + adequacy of dosing using serum concentration monitoring. +
        +
        + +
        + + + + + + + + + + + + + + + + + + + +
        Usual Dose (UD) Normal Renal Function400 mg/day
        CrCl 30-90UD
        CrCL <30 or HemodialysisUD
        Peritoneal DialysisData currently are not available for patients receiving peritoneal dialysis. Until data + become available, begin with doses recommended for patients receiving hemodialysis and verify + adequacy of dosing using serum concentration monitoring. +
        +
        + +
        + + + + + + + + + + + + + + + + + + + +
        Usual Dose (UD) Normal Renal Function15 mg/kg/daily or thrice weekly
        CrCl 30-90UD
        CrCL <30 or Hemodialysis15 mg/kg/dose thrice weekly
        Peritoneal DialysisData currently are not available for patients receiving peritoneal dialysis. Until data + become available, begin with doses recommended for patients receiving hemodialysis and verify + adequacy of dosing using serum concentration monitoring. +
        +
        + +
        + + + + + + + + + + + + + + + + + + +
        Usual Dose (UD) Normal Renal Function600 mg/day
        CrCl 30-90UD
        CrCL <30 or Hemodialysis600 mg/dose thrice weekly
        Peritoneal DialysisData currently are not available for patients receiving peritoneal dialysis. Until data + become available, begin with doses recommended for patients receiving hemodialysis and verify + adequacy of dosing using serum concentration monitoring. +
        +
        +
        • Standard doses are given unless there is intolerance.
        • The medications should be given after hemodialysis on the day of hemodialysis.
          • @@ -659,46 +956,132 @@

          Table 13: Antituberculosis Antibiotics in Adult Patients with R

        -

        Table 14: Antituberculosis medications which may be used for patients who have contraindications to or intolerance of first line agents or who require IV therapy during acute or critical illness

        +

        Table 14: Antituberculosis medications which may be used for patients who have contraindications to or intolerance of first line agents or who require IV therapy during acute or critical illness

        - - - - - - - - - - - - - - - - - - - - - - - - - - - + +
        +
          +
          • + +
        • + +
          • + +
          • + +
          • +
        +
        + +
        +
        Medication: Route(s)Dosing (A for adults, C for children)Adverse Reactions
        Levofloxacin: PO/IVA: 750 mg daily C: 15 – 20 mg/kg daily Max dose 750 mgGI upset, dizziness, hypersensitivity, Headaches, QT prolongation, tendon rupture - (rare), arthralgia, increased risk for aortic dissection/rupture, hypo/hyperglycemia -
        Moxifloxacin: PO/IVA: 400 mg daily C: no established dose
        Linezolid: PO/IVA: 600 mg (once daily) C: 10 mg/kg/dose every 12 hours (max dose 600 mg)Myelosuppression, GI upset, optic and peripheral neuropathy (may be irreversible)
        Amikacin: IVA: 10 to 15 mg/kg/day 5-7 days per week or 3 times per week - C: 15 to 30 mg/kg/day (max dose 1 gram) 5-7 days per week or 3 times per week - Auditory, vestibular and renal toxicity
        + + + + + + + + + + +
        Dosing (A for adults, C for children) + A: 750 mg daily
        + C: 15 – 20 mg/kg daily
        + Max dose: 750 mg +
        Adverse Reactions + GI upset, dizziness, hypersensitivity, Headaches, QT prolongation, tendon rupture (rare), arthralgia, increased risk for aortic dissection/rupture, hypo/hyperglycemia +
        + +

        + Expert consultation is advised before use; agent is not approved for children less than 18 years of age. +

        +
        + +
        + + + + + + + + + + + +
        Dosing (A for adults, C for children) + A: 10-15 mg/kg
        + C: No established dose
        + Max dose: 400 mg +
        Adverse Reactions + GI upset, dizziness, hypersensitivity, Headaches, QT prolongation, tendon rupture (rare), arthralgia, increased risk for aortic dissection/rupture, hypo/hyperglycemia +
        + +

        + Expert consultation is advised before use; agent is not approved for children less than 18 years of age. +

        +
        + +
        + + + + + + + + + + +
        Dosing (A for adults, C for children) + A: 600 mg (once daily)
        + C: + Children < 12 years: +
          +
        • 5 – 10 kg: 15 mg/kg once daily
          • +
        • 10 – 23 kg: 12 mg/kg once daily
          • +
        • >23 kg: 10 mg/kg once daily
          • +
        + Children ≥12 years: +
          +
        • 10 mg/kg once daily
          • +
        + Max dose: 600 mg +
        Adverse Reactions + Myelosuppression, GI upset, optic and peripheral neuropathy (may be irreversible) +
        + +
        + + + + + + + + + + + +
        Dosing (A for adults, C for children) + A: 10 to 15 mg/kg/day
        + 5-7 days per week or 3 times per week

        + + C: 15 to 30 mg/kg/day (max dose 1 gram)
        + 5-7 days per week or 3 times per week +
        Adverse Reactions + Auditory, vestibular and renal toxicity +
        +
        +
        -

        Table 15: Clinical Situations for which standard therapy cannot be given or is not well- tolerated or may not be effective: Potential Alternative Regimens (Dosing and/or Drugs)

        +

        Table 15: Clinical Situations for which standard therapy cannot be given or is not well- tolerated or may not be effective: Potential Alternative Regimens (Dosing and/or Drugs)

        @@ -816,4 +1199,5 @@

        Table 15: Clinical Situations for which standard therapy cannot + diff --git a/app/src/main/assets/pages/5_treatment_of_current_(active)_disease_therapy__d__drug_resistance.html b/app/src/main/assets/pages/5_treatment_of_current_(active)_disease_therapy__d__drug_resistance.html index 01c8e75..f47eeb5 100644 --- a/app/src/main/assets/pages/5_treatment_of_current_(active)_disease_therapy__d__drug_resistance.html +++ b/app/src/main/assets/pages/5_treatment_of_current_(active)_disease_therapy__d__drug_resistance.html @@ -16,29 +16,39 @@
        +
        +
        +
        +
        + +
        +

        V. Treatment of Current (Active) Disease Therapy

        +
        +

        Last Updated October 2025

        +
        +
        +
        +

        + Seek expert consultation for all patients with suspected or proven drug-resistant TB. Treatment of active TB disease caused by drug- resistant organisms should be done by or in close consultation with an expert in the management of these difficult situations. +

        -

        Seek expert consultation for all patients with suspected or proven drug-resistant TB. Treatment of TB caused by - drug- - resistant organisms should be done by or in close consultation with an expert in the management of these - difficult - situations. INH-resistant TB is the most common form of drug-resistant TB (with a global prevalence of >10%). - Newly - updated ATS/CDC/ IDSA recommendations for the treatment of drug-resistant TB recommend the addition of later - generation fluoroquinolones (i.e., levofloxacin or moxifloxacin) to rifampin, pyrazinamide, and ethambutol for - the - treatment of INH-resistant TB, although there are limited data on the benefit of the addition of the - fluoroquinolone - in these circumstances. Multidrug-resistant (MDR)-TB is defined as resistance to at least INH and rifampin. New - and - repurposed anti-TB drugs included in treatment regimens have provided new options for the treatment of MDR-TB. +

        + INH-resistant TB is the most common form of drug-resistant TB (with a global prevalence of >10%). Updated ATS/CDC/ IDSA recommendations for the treatment of drug-resistant TB recommend the addition of later generation fluoroquinolones (i.e., levofloxacin or moxifloxacin) to rifampin, pyrazinamide, and ethambutol for the treatment of INH-resistant TB, although there are limited data on the benefit of the addition of the fluoroquinolone in these circumstances. +

        + +

        + Multidrug-resistant (MDR)-TB is defined as resistance to at least INH and rifampin. New and repurposed anti-TB drugs included in treatment regimens have provided new options for the treatment of MDR-TB including 6-9 month regimens using BPaL (bedaquiline, pretomanid, and levofloxacin) or BPaLM (BPaL plus moxifloxacin). +

        +

        As noted, consultation with an expert is required for MDR-TB and other drug-resistant TB cases. Second line treatment regimens often represent the patient’s last best hope for being cured. Inappropriate management can have - life-threatening consequences. If you think, identify, or suspect rifampin-resistant or MDR disease in a - person with TB, contact the state consultants by direct email, Susan Ray sray02@emory.edu or Marcos Schechter - mcoutin@emory.edu, or by telephoning the State TB Program at 404-657-2597 for diagnostic and treatment support. - There are multiple strategies to pursue rapid genotypic assessment for drug resistance. Additionally, there are + life-threatening consequences.

        +

        + If you think, identify, or suspect rifampin-resistant or MDR-TB disease in a person with TB, contact the state consultants by direct email, Dr. Susan Ray sray02@emory.edu or Dr. Marcos Schechter mcoutin@emory.edu, or by telephoning the Georgia Department of Public Health TB Program at 404-657-2597 for diagnostic and treatment support. There are multiple strategies to pursue rapid genotypic assessment for drug resistance. +

        +

        Additionally, there are several exciting new regimens with strong outcomes that require expert consultation. See Appendix and/or website for making contact with an appropriate expert in your diff --git a/app/src/main/assets/pages/5_treatment_of_current_(active)_disease_therapy__e__monitoring_patients_on_therapy_for_response_and_adverse_events.html b/app/src/main/assets/pages/5_treatment_of_current_(active)_disease_therapy__e__monitoring_patients_on_therapy_for_response_and_adverse_events.html index 2106562..cf3b423 100644 --- a/app/src/main/assets/pages/5_treatment_of_current_(active)_disease_therapy__e__monitoring_patients_on_therapy_for_response_and_adverse_events.html +++ b/app/src/main/assets/pages/5_treatment_of_current_(active)_disease_therapy__e__monitoring_patients_on_therapy_for_response_and_adverse_events.html @@ -15,95 +15,82 @@

        +
        +
        +
        +
        + +
        +

        V. Treatment of Current (Active) Disease Therapy

        +
        +

        Last Updated October 2025

        +
        +
        +
          -
        1. Response to Treatment
          2. -
            -
          1. For patients with pulmonary TB, obtain sputum for AFB smear and culture at least monthly until two - consecutive sputum samples are culture negative. Some authorities prefer to obtain monthly AFB sputum - smear - and cultures throughout the course of therapy. -
            2. +
          2. + Response to Treatment ⌃ +
            +
              +
            1. + For patients with pulmonary TB, obtain sputum for AFB smear and culture at least monthly until two consecutive sputum samples are culture negative. Some authorities prefer to obtain monthly AFB sputum smear and cultures throughout the course of therapy. +
              2. +
            2. + Patients with cavitary pulmonary TB who have a positive 2-month sputum culture are at increased risk for relapse if treated with only 6 months of therapy for drug-susceptible TB. If the 2-month culture remains positive or if symptoms do not resolve, request repeat drug susceptibility testing to evaluate for acquired drug resistance. Additionally, review information -
            3. Patients with cavitary pulmonary TB who have a positive 2 -month sputum culture are at increased risk - for - relapse if treated with only 6 months of therapy. If the 2-month culture remains positive or if symptoms - do - not resolve, request repeat drug susceptibility testing to evaluate for acquired drug resistance. - Additionally, review information related to treatment adherence. For any patient receiving - self-administered - therapy (this should be very rare as DOT is our standard of care) who has a positive 2-month culture, - DOT - should be initiated. -
              4. - -
            4. For patients with drug susceptible disease who have positive 2-month culture and have cavitary disease - on - their initial CXR, the continuation phase should be increased to 7 months so that they receive a total - of 9 - months of therapy. -
              5. - -
            5. Factors to be considered in deciding whether to prolong treatment in patients with either cavitation on - initial CXR or a positive culture after 2 months of therapy (but not both) include being more than 10% - underweight at diagnosis, having HIV infection or having extensive involvement on CXR. -
              6. -
            6. HIV testing should be performed on all persons diagnosed with TB.
              7. -
            -
          3. Monitoring for Adverse Reactions
            4. -
              -
            1. Obtain the following baseline measurements to detect any abnormality that would complicate the regimen - or - necessitate its modification: -
              2. -
                -
              • Hepaticenzyme (e.g.,AST) level, bilirubin, serumcreatinine, complete blood count and platelet count. -
                • -
              • Baseline visual acuity (if EMB is used)
                • -
              • Baseline audiometry (if Amikacin is used).
                • -
              • CD4 count and HIV viral load for patients with HIV infection.
                • -
              - -
            2. Patients with epidemiologic risk factors for hepatitis B or C (e.g., injection drug use, birth in Asia - or - Africa, HIV infection) should have serologic tests for these viruses performed. -
              3. - -
            3. All patients should be seen at least monthly and questioned about potential adverse reactions. If - symptoms - suggesting drug toxicity occur, appropriate laboratory testing should be performed to confirm or exclude - such toxicity. Patients should be instructed to report symptoms of hepatitis (which can be induced by - INH, - RIF and/or PZA) immediately. Such symptoms include nausea, loss of appetite, vomiting, jaundice (dark - urine, - yellow skin), malaise, unexplained fever for > 3 days, or abdominal tenderness. If patients have - jaundice or - symptoms of liver disease, discontinue medications immediately and consult a specialist. -
              4. - -
            4. Routine monthly laboratory monitoring is generally not required for those with normal baseline and no - underlying disease. Monitor hepatic enzymes monthly if baseline levels are elevated, and for those with - HIV - infection, history of alcoholism, chronic liver disease, concomitant use of other drugs which can cause - hepatotoxicity, or pregnancy. At least 20% of patients will have elevated hepatic enzymes; asymptomatic - elevation less than five times the upper limit of normal is not an indication to stop treatment in - asymptomatic patients. If patients have jaundice or symptomatic liver disease, discontinue medications - immediately and consult a specialist -
              5. - -
            5. Patients receiving EMB should be questioned regarding visual disturbances at monthly intervals; monthly - repeat testing of visual acuity and color vision is recommended for patients receiving an EMB dose - exceeding - 15—20 mg/ kg (recommended range) and for patients receiving EMB for more than two months. -
              6. - -
            6. Pyridoxine will usually prevent INH-induced neurotoxicity (peripheral neuropathy).
              7. -
            7. Hyperuricemia may occur in patients on PZA but acute gout is uncommon. Asymptomatic hyperuricemia is not - an - indication for discontinuing the drug. -
              8. - - -
            +related to treatment adherence. For any patient receiving self-administered therapy (this should be very rare as DOT is our standard of care) who has a positive 2-month culture, DOT should be initiated. + +
          4. + For patients with drug-susceptible active TB disease who have positive 2-month culture and have cavitary disease on their initial CXR, the continuation phase should be increased to 7 months so that they receive a total of 9 months of therapy. +
            5. +
          5. Factors to be considered in deciding whether to prolong treatment in patients with either cavitation on + initial CXR or a positive culture after 2 months of therapy (but not both) include being more than 10% + underweight at diagnosis, having HIV infection or having extensive involvement on CXR. +
            6. +
          6. HIV testing should be performed on all persons diagnosed with TB.
            7. +
          +
        + +
      • + Monitoring for Adverse Reactions ⌃ +
        +
          +
        1. Obtain the following baseline measurements to detect any abnormality that would complicate the regimen + or necessitate its modification: +
            +
          • Hepatic enzyme (e.g., AST) level, bilirubin, serum creatinine, complete blood count and platelet count.
            • +
          • Baseline visual acuity (if EMB is used)
            • +
          • Baseline audiometry (if Amikacin is used).
            • +
          • CD4 count and HIV viral load for patients with HIV infection.
            • +
          +
          2. +
        2. Patients with epidemiologic risk factors for hepatitis B or C (e.g., injection drug use, birth in Asia + or Africa, HIV infection) should have serologic tests for these viruses performed. +
          3. +
        3. All patients should be seen at least monthly and questioned about potential adverse reactions. If + symptoms suggesting drug toxicity occur, appropriate laboratory testing should be performed to confirm or exclude + such toxicity. Patients should be instructed to report symptoms of hepatitis (which can be induced by + INH, RIF and/or PZA) immediately. Such symptoms include nausea, loss of appetite, vomiting, jaundice (dark + urine, yellow skin), malaise, unexplained fever for > 3 days, or abdominal tenderness. If patients have + jaundice or symptoms of liver disease, discontinue medications immediately and consult a specialist. +
          4. +
        4. + Routine monthly laboratory monitoring is generally not required for those with normal baseline and no underlying disease. Monitor hepatic enzymes monthly if baseline levels are elevated, and for those with HIV infection, history of alcohol use disorder, chronic liver disease, concomitant use of other drugs which can cause hepatotoxicity, or pregnancy. At least 20% of patients will have elevated hepatic enzymes; asymptomatic elevation less than five times the upper limit of normal is not an indication to stop treatment in asymptomatic patients. If patients have jaundice or symptomatic liver disease, discontinue medications immediately and consult a specialist. +
          5. +
        5. Patients receiving EMB should be questioned regarding visual disturbances at monthly intervals; monthly + repeat testing of visual acuity and color vision is recommended for patients receiving an EMB dose + exceeding 15—20 mg/ kg (recommended range) and for patients receiving EMB for more than two months. +
          6. +
        6. Pyridoxine will usually prevent INH-induced neurotoxicity (peripheral neuropathy) and is recommended for all patients on INH.
          7. +
        7. Hyperuricemia may occur in patients on PZA but acute gout is uncommon. Asymptomatic hyperuricemia is not + an indication for discontinuing the drug. +
          8. +
        8. + For patients who are unable to tolerate standard therapy, please contact the state consultants by direct email, Dr. Susan Ray sray02@emory.edu or Dr. Marcos Schechter mcoutin@emory.edu, or by telephoning the Georgia Department of Public Health TB Program at 404-657-2597 for diagnostic and treatment support. +
          9. +
        +
        +
        • @@ -111,4 +98,5 @@ + diff --git a/app/src/main/assets/pages/5_treatment_of_current_(active)_disease_therapy__f__tb_and_hiv.html b/app/src/main/assets/pages/5_treatment_of_current_(active)_disease_therapy__f__tb_and_hiv.html index d89a942..6086de0 100644 --- a/app/src/main/assets/pages/5_treatment_of_current_(active)_disease_therapy__f__tb_and_hiv.html +++ b/app/src/main/assets/pages/5_treatment_of_current_(active)_disease_therapy__f__tb_and_hiv.html @@ -1,6 +1,7 @@ + @@ -10,82 +11,825 @@ + + +
        +
        +
        +
        +
        + +
        +

        V. Treatment of Current (Active) Disease Therapy

        +
        +

        Last Updated October 2025

        +
        +
        +
        +

        + Treatment of persons living with HIV with active TB disease should be carried out in consultation with a + physician who has experience in the use of rifamycin drugs and antiretroviral agents. + Recommendations on the treatment of TB in combination with antiretroviral therapy continue to evolve, and it + is important to check for updated guidelines: + https://clinicalinfo.hiv.gov/en/guidelines and + + https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-arv/tuberculosishiv-coinfection?view=full + +

        + Antiretroviral therapy (ART)⌃ +
        +
          +
        • + Improves outcomes for persons living with HIV and decreases HIV-related mortality as well as risk of + relapse. Persons living with HIV in the United States with active TB disease commonly have advanced + HIV/AIDS with low CD4 counts and high plasma HIV RNA levels; all patients with TB who have HIV + co-infection should receive treatment for HIV with ART. +
          • +
        +
        + Timing of ART⌃ +
        +
          +
        • + Multiple studies have demonstrated the benefits of ART initiation among persons living with HIV + during TB treatment, including a reduction in mortality. +
          • +
        • + However, the use of ART among persons living with HIV with active TB disease is complicated by + overlapping toxicity profiles of some antituberculosis and antiretroviral drugs; complex drug-drug + interactions; and the occurrence of “paradoxical” reactions or immune reconstitution inflammatory + syndrome (IRIS). +
          • +
        +
        + All persons living with HIV who are diagnosed with active + TB disease and not on ART should be started on ART as follows:⌃ +
        +
          +
        • + CD4 T lymphocyte (CD4) cell counts <50 cells/mm3: HHS guidelines recommend + initiating ART as soon as possible, but within 2 weeks of starting TB treatment. +
          • +
        • + CD4 counts ≥50 cells/mm3: Initiate ART within 2 to 8 weeks of starting TB + treatment. +
          • +
        • + During pregnancy, regardless of CD4 count: Initiate ART as early as feasible for treatment of + the person with HIV and prevention of HIV transmission to the infant. +
          • +
        • + With TB meningitis: Initiate ART after TB meningitis is under control and after at least 2 + weeks of anti-TB treatment to reduce the risk of life-threatening inflammation in a closed space + (i.e., brain) as a result of immune reconstitution. Generally, initiation of ART in this setting is + recommended 4 to 8 weeks after initiation of therapy for TB meningitis. +
          • +
        +
        + + +

        + As noted above, there are certain situations where ART therapy should be delayed when treating persons with + active TB disease who have HIV co-infection. A study of people living with HIV with TB meningitis found that + early ART was associated with an increase in severe adverse events and no mortality benefit. Thus, timing of + ART initiation in persons with active TB disease who have HIV co-infection should take into account both the + degree of immune suppression and site of disease (see Table 16 and recommendations above). +

        +

        Table 16. Antiretroviral Therapy (ART) and Treatment of Persons + Living with HIV and Active TB

        +
        + + + + + + + + + + + + + + + + + + + + + + +
        HHS Panel Recommendations on treatment of Tuberculosis Disease with HIV + co-infection: Timing of Antiretroviral Therapy (ART) Initiation relative to TB treatment +
        CD4 count and/or clinical status at time of TB diagnosisART Initiation
        + < 50 cells/mm³within 2 weeks of starting TB therapy.
        > 50 cells/mm³within 2-8 weeks of starting TB therapy
        Pregnant, any CD4 countAs early as feasible
        +

        ** EXCEPTION: tuberculous meningitis. To avoid life-threatening CNS immune reconstitution inflammatory + syndrome (IRIS), persons living with HIV and tuberculous meningitis should not + + be started on ART until AFTER the TB meningitis is under control and at least two weeks anti-TB treatment +

        +

        + PREVENTING IRIS (Immune Reconstitution Inflammatory Syndrome): prednisone 40 mg/day for 2 weeks followed by 20 mg/day for 2 weeks is recommended for people with CD4 100 cells/mm3 who start ART within 30 days of TB treatment, are responding well to treatment, do not have known or suspected rifampin resistance, Kaposi sarcoma, or active hepatitis B. This recommendation does not apply to people with CNS TB for whom steroids are recommended from the time TB treatment is started. +

        +

        + Above based on guidelines developed by the Department of Health and Human Services (DHHS) Panel on Guidelines for Use of Antiretroviral Agents for Adults and Adolescents and Use of Antiretroviral Drugs in Pregnant Women living with HIV and Interventions to Reduce Perinatal Transmission in the United States, last reviewed and updated October 29, 2024 (https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-opportunistic-infections/mycobacterium?view=full) +

        + +
        + +

        Table 17. Antiretroviral Therapy (ART) and Treatment of Persons + Living with HIV and Active TB

        +
        + + + + + + + + + + + + + + + + + + + +
        Principle: Despite Drug Interactions, a Rifamycin (Rifampin or Rifabutin) Should Be Included + in TB Regimens for Patients + Receiving ART, with Dosage Adjustment if Necessary (see Table SMR11 for dosage + adjustments). +
        Option 1: Integrase-based ART regimens. Dolutegravir is the preferred integrase for TB/HIV co-infection treatment.

        + Option 1a: Patients receiving rifampin-based TB treatment.

        + Preferred: DTG (Tivicay) BID + TDF/FTC (Truvada) daily
        + Alternative choices:
        + + (1) DTG (Tivicay) BID + TAF/FTC (Descovy) daily
        + + (2) DTG (Tivivay) BID + ABC/3TC daily (note: Triumeq is a combination of + + DTG/ABC/3tc)

        + Option 1b: Patients receiving rifabutin-based TB treatment

        + Preferred: DTG (Tivicay) daily + TDF/FTC (Truvada) daily
        + + Alternative choices:
        + + (1) DTG (Tivicay) daily + TAF/FTC (Descovy) daily
        + + (2) DTG/ABC/3TC (Triumeq) daily

        + + + Note: The FDA does not recommend using TAF with rifampin or rifabutin +
        + Option 2: PI-based ART regimens (cannot be used with rifampin, must use with dose-adjusted rifabutin)

        + Option 2a

        + ATV/r daily + TDF/FTC (Truvada) daily
        + Alternative choices:

        + + (1) ATV/r daily + TAF/FTC (Descovy) daily
        + + (2) ATV/r daily + ABC/3TC daily

        + + Option 2b

        + DRV/r daily + TDF/FTC (Truvada) daily

        + + (1) DRV/r daily + TAF/FTC (Descovy) daily
        + (2) DRV/r daily + ABC/3TC daily +
        + 1- PI’s have high barrier to resistance. However, given rifabutin is given at half-dose when used with PI’s adherence to ART should be closely monitored. Poor adherence to PI’s while on rifabutin increases risk for rifampin resistance.
        + + 2- The FDA does not recommend using TAF with rifampin or rifabutin.
        + + 3- Cobicistat cannot be used with rifabutin +
        + Choice for Pregnant Women living with HIV and with Active TB : Expert consultation advised. Options 1a and 1b are currently preferred in pregnancy. +
        + +
          +
        • NRTIs: nucleoside/-tide reverse transcriptase inhibitors
          • +
        • NNRTIs: non-nucleoside reverse transcriptase inhibitors
          • +
        • PIs: protease inhibitors
          • +
        • /r: boosted with ritonavir
          • +
        • TDF: Tenofovir disoproxil fumarate
          • +
        • TAF: Tenofovir alafenamide
          • +
        • FTC: Emtricitabine
          • +
        • 3TC: Lamivudine
          • +
        • ABC: Abacavir
          • +
        • ATV/r: Atazanavir/ritonavir
          • +
        • DRV/r: Daraunavir/ritonavir
          • +
        • DTG: Dolutegravir
          • +
        +

        + Above based on guidelines developed by the Department of Health and Human Services (DHHS) Panel on Guidelines for Use of Antiretroviral Agents for Adults and Adolescents and Use of Antiretroviral Drugs in Pregnant Women living with HIV and Interventions to Reduce Perinatal Transmission in the United States, last reviewed and updated October 29, 2024 (http://aidsinfo.nih.gov/guidelines). +

        + +
        + +

        + Persons who are already on ART at the time of TB diagnosis, generally should be continued on the ART + treatment (though ART regimen may need to be adjusted). +

        +

        Choice of ART⌃

        +
        +
          +
        • + Because of the potential for significant drug interactions and overlapping toxicities, the choice of + ART among persons living with HIV who have active TB disease should be made only after direct + communication between HIV and tuberculosis care providers. +
          • +
        • + Any change in either the TB medications or the ART regimen should be immediately shared between the + two providers. +
          • +
        +
        + +

        There are clinically important drug-drug interactions between + the rifamycins (e.g., rifampin, rifabutin, rifapentene) and some of the antiretroviral drugs, especially + integrase and protease inhibitors.⌃

        +
        +
          +
        • + The rifamycins are inducers of the cytochrome P450-3A (CYP3A) system in the liver and thereby + decrease serum concentrations of drugs metabolized by this system including integrase and protease + inhibitors. +
          • +
        • + Rifampin is a potent inducer of the CYP3A, while rifabutin is a less potent inducer. Rifampin cannot + be given with most protease inhibitors because it results in low serum levels of these drugs. +
          • +
        • + Rifabutin has less of an effect and therefore can be used with certain protease inhibitors as + described below. +
          • +
        • + Rifampin and rifabutin can be given with certain integrase inhibitors (https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-arv/drug-interactions-insti). +
          • +
        +
        +

        + The protease inhibitors also affect rifamycin metabolism and because the rifamycin metabolism is retarded by + these drugs, the dose of rifabutin needs to be reduced in order to avoid rifabutin related toxicity. +

        +

        + Despite these drug-drug interactions, a rifamycin (rifampin or rifabutin) should ALWAYS be included in the + treatment regimen for drug-susceptible TB among persons living with HIV. +

        + +

        Rifampin can be given with the following + antiretrovirals:⌃

        +
        +
          +
        • + MOST Nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs) (e.g., zidovudine, lamivudine, + emtricitabine, tenofovir disoproxil fumarate (TDF), + + abacavir). Tenofovir alafenamide (TAF) is not currently recommended for use in combination with + rifamycins. +
          • +
        • + SELECTED Non-nucleoside reverse transcriptase inhibitors (NNRTIs): efavirenz only (all others are + contraindicated for coadministration with rifampin). +
          • +
        • + Selected Integrase inhibitors: raltegravir and dolutegravir. The dose of raltegravir must be + increased to 800 mg twice daily (BID) and the dose of dolutegravir must be increased to 50 mg BID + for patients on rifampin. Neither raltegravir or dolutegravir require a dosing change when used with + rifabutin. Bictegravir (a component of Biktarvy) should NOT be given in combination with any + rifamycin drugs (rifampin, rifabutin, rifapentine). +
          • +
        +
        + +

        Rifampin should NOT be used with the following:⌃

        +
        +
          +
        • + Tenofoviral afenamide (TAF) +
          • +
        • + Protease inhibitors +
          • +
        • + Nevirapine, etravirine, rilpivarine (NNRTIs) +
          • +
        • + Bictegravir (including Biktarvy), elvitegravir +
          • +
        +
        +

        + A summary of preferred treatment options for patients with tuberculosis disease who are HIV co-infected is + shown in + Table 18 and + Table 19. For additional + information refer to updated HHS guidelines, visit https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-arv/tuberculosishiv-coinfection?view=full +

        +

        Table 18. Dosage Adjustments for ART and Rifamycins when used in + Combination

        +
        +
        + + + +
        -
        - -

        HIV is the most important risk factor for active TB disease and TB-related mortality. TB is one of the few - co-infections occurring in HIV-infected persons which is transmissible, curable and preventable. Importantly, - HIV is - a risk factor for active TB across all CD4 count levels.

        - -

        Persons with HIV infection may have diminished (or absent) tuberculin skin test reaction and/or negative IGRA - because of immunosuppression. Therefore, tuberculin reactions of > 5 mm of induration are considered indicative - of - TB infection in an HIV- infected individual (see B. Criteria for a Positive Tuberculin Test, by Risk Group). Standard IGRA cut-offs apply for patients - with - HIV despite reduced sensitivity of IGRA test among patients with HIV.

        - -

        Because HIV status is a critical factor in the treatment of TB, HIV counseling and testing should be offered to - all - patients with proven or suspected active TB disease.

        - -

        The clinical presentation of TB in a person living with HIV may differ from that in persons without HIV. Apical - pulmonary disease with cavitation, a classic finding in immunologically competent persons, is less common among - persons living with HIV, especially among those with low CD4 counts. HIV-infected patients may present with - infiltrates in any lung zone and/or with mediastinal or hilar lymphadenopathy. Extrapulmonary and disseminated - TB - are common among HIV-infected TB patients. -

        - -

        Treatment for Individuals with TB & HIV

        -
          -
        1. The treatment of TB in persons living with HIV is similar to that for patients without HIV infection. - However, - intermittent therapy should be avoided, and twice-weekly regimens are contraindicated. -
          2. - -
        2. Persons living with HIV with active TB disease should be initiated on a 4-drug treatment regimen (INH, RIF - (or - Rifabutin), PZA and EMB) and pyridoxine as outlined in Table 7, unless contraindications to - medication exist. The use of antiretroviral therapy and TB medications is discussed on Antiretroviral Therapy During the Course of TB Therapy. - Persons living with HIV with drug-susceptible TB disease generally respond well to standard anti-TB drugs. -
          3. - -
        3. Patients with HIV co-infection who have drug-susceptible TB disease should be treated for a minimum of 6 months with antituberculosis therapy. Duration of therapy should be prolonged for patients with delayed or slow - response to therapy. Persons living with HIV with TB disease should be monitored closely for clinical and - bacteriological response. Many experts extend treatment duration to 9 months for all patients with HIV, but - prolonged treatment beyond 6 months is especially recommended for patients who do not achieve HIV viral - suppression during TB treatment and/or are slow to respond to therapy, including patients who remain culture - positive after two months of therapy. Because patient adherence to therapy is critical for good outcomes, - DOT is - the standard of care and is strongly recommended for all patients with active TB including persons living - with - HIV. -
          4. - -
        4. Persons living with HIV with TB disease should be monitored very closely during therapy as they appear to - have a - greater frequency of adverse reactions to anti-TB drugs. -
          5. - -
        5. HIV viral load should be monitored very closely during TB therapy given drug-drug interactions. Viral load - should be measured prior to antiretroviral therapy (ART) initiation and within 2—4 weeks but no later than 8 - weeks after ART initiation. An HIV viral load should be measured every 3 months among patients with stable - ART - regimen and suppressed viral load. -
          6. - -
        6. After treatment for TB disease is completed, patients should be reminded that if symptoms reappear, they - should - seek prompt medical evaluation. -
          7. -
        - -
        +
        +

        Dolutegravir (DTG)

        + + + + + + + + + + + + + + + +
        DrugDosing
        Rifampin (RIF)RIF: No change (600 mg)
        DTG: Increase to 50 mg BID
        Rifabutin (RBT)RBT: No change (300 mg)
        DTG: No change (50 mg)
        +
        + +
        +

        ATV/r, DRV/r

        + + + + + + + + + + + + + + + +
        DrugDosing
        Rifampin (RIF)DO NOT USE
        Rifabutin (RBT)RBT: decrease to 150 mg/d
        PIs: no change
        +
        + +
        +

        Efavirenz (EFV)
        (Note: No longer a first line ART)

        + + + + + + + + + + + + + + + +
        DrugDosing
        Rifampin (RIF)RIF no change (600 mg)
        EFV: no change (600 mg qhs)
        Rifabutin (RBT)DO NOT USE
        +
        +

        + Department of Human Health Services links for ART drug-drug interactions – these are updated frequently +

        +

        Protease inhibitors: https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-arv/drug-interactions-protease-inhibitors?view=full +

        + +

        NNRTIs: https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-arv/drug-interactions-nnrti?view=full +

        + +

        NRTIs: https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-arv/drug-interactions-nrti?view=full +

        + +

        Integrase inhibitors: https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-arv/drug-interactions-insti?view=full +

        + +

        *Preliminary data suggest that there is an increased risk of neural tube defects in infants born to women + who were receiving DTG at the time of conception. DTG is contraindicated for pregnant women during first + trimester and for women who are planning to become pregnant or are not using effective contraception. + DTG is the preferred integrase inhibitor after first trimester.

        + +
          +
        • NNRTIs: non-nucleoside reverse transcriptase inhibitors
          • +
        • PIs: protease inhibitors
          • +
        • ATV/r: Atazanavir/ritonavir
          • +
        • DRV/r: Daraunavir/ritonavir
          • +
        • LPV/r: Lopinavir/ritonavir
          • +
        • RAL: Raltegravir
          • +
        • DTG: Dolutegravir
          • +
        • /c : boosted with cobicistat
          • +
        + +

        Table 18 is based on guidelines developed by the Department of Health and Human Services (DHHS) Panel on + Guidelines for Use of Antiretroviral Agents for Adults and Adolescents and Use of Antiretroviral Drugs + in Pregnant Women with HIV Infection and Interventions to Reduce Perinatal Transmission in the United + States, last reviewed and updated April 15, 2019 + (aidsinfo.nih.gov/guidelines) +

        + +

        1-Data on integrase inhibitors and pregnancy outcomes is rapidly evolving and DHHS + guidelines are frequently updated.

        + +

        2-Cobicistat is currently not recommended for pregnant women.

        + +

        Table 19. Adjunctive Use of Corticosteroid Therapy

        +
        +
        + + + + + + + + + + +
        + +
        + + + + + + + + + + + + + + + +
        Length of therapy6 months
        CorticosteroidsNot recommended
        Additional management considerationsPursue microbiologic proof of diagnosis prior to starting Rx
        +
        + +
        + + + + + + + + + + + + + + + +
        Length of therapy6 to 9 months
        CorticosteroidsNot recommended
        Additional management considerationsExtend to 12 months if hardware is present
        +
        + +
        + + + + + + + + + + + + + + + +
        Length of therapy6 to 9 months
        CorticosteroidsNot recommended for TB rx but may be indicated for cord compression
        Additional management considerationsMost spine infection can be cured with medical Rx. Surgery indicated for relief of + cord + compression, progressive disease despite medical therapy, instability of the spine. +
        +
        + +
        + + + + + + + + + + + + + + + + + + + +
        Length of therapy9 to 12 months
        CorticosteroidsStrongly recommended
        Steroid dosingA and C ≥ 25kg: 12 mg/day of dexamethasone x 3 weeks followed by 3-week taper +

        C < 25kg: 8 mg/day of dexamethasone for 3 weeks followed by 3-week taper

        +
        Additional management considerationsMost spine infection can be cured with medical Rx. Surgery indicated for relief of + cord + compression, progressive disease despite medical therapy, instability of the spine. +
        +
        + +
        + + + + + + + + + + + + + + + +
        Length of therapy9-12 months
        CorticosteroidsStrongly recommended
        Additional management considerationsNegative CSF culture or PCR test does NOT exclude this diagnosis +

        Follow CSF profile for response to therapy

        +
        +
        + +
        + + + + + + + + + + + + + + + +
        Length of therapy6 months
        CorticosteroidsNot recommended
        Additional management considerationsEmpyema may require decortication
        +
        + +
        + + + + + + + + + + + + + + + +
        Length of therapy6 months
        CorticosteroidsNO LONGER routinely RECOMMENDED
        Additional management considerationsConsider steroids for patients at highest risk of later constriction: + large pericardial effusions high levels of inflammatory cells or markers in + pericardial fluid those + with early signs of constriction
        +
        + +
        + + + + + + + + + + + + + + + +
        Length of therapy6 months
        CorticosteroidsNot recommended
        Additional management considerationsObtain cultures from blood, urine and sputum in addition to clinically apparent + sites of disease.
        +
        + +
        + + + + + + + + + + + + + + + +
        Length of therapy6 months
        CorticosteroidsNot recommended
        Additional management considerations
        +
        + +
        + + + + + + + + + + + + + + + +
        Length of therapy6 months
        CorticosteroidsNot recommended
        Additional management considerations
        +
        + +

        + 2 mg/kg prednisone daily over three weeks, followed by taper Maximum dose 60 mg
        OR
        + Dexamethasone 0.3-0.6 mg/kg daily over three weeks, followed by taper Round to nearest tablet size + (2, 4, 6 mg) Maximum dose 12 mg +

        +
        +
        - + + + + diff --git a/app/src/main/assets/pages/5_treatment_of_current_(active)_disease_therapy__figure1.html b/app/src/main/assets/pages/5_treatment_of_current_(active)_disease_therapy__figure1.html deleted file mode 100644 index cd350aa..0000000 --- a/app/src/main/assets/pages/5_treatment_of_current_(active)_disease_therapy__figure1.html +++ /dev/null @@ -1,33 +0,0 @@ - - - - - - - - GA TB Reference Guide - - - - - - - - -

        Figure 1. Factors to be considered in deciding to initiate treatment empirically for active tuberculosis (TB) (prior - to microbiologic confirmation)

        - -Figure 1 - -

        Abbreviations: AFB, acid-fast bacilli; HIV, human immunodeficiency virus; IGRA, interferon-γ release assay; Mtb, - Mycobacterium tuberculosis; TNF, tumor necrosis factor; TST, tuberculin skin test.

        -

        Clin Infect Dis, Volume 63, Issue 7, 1 October 2016, Pages 853–867, https://doi.org/10.1093/cid/ciw566 -

        - -

        Unless provided in the caption above, the following copyright applies to the content of this slide: © The Author - 2016. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For - permissions, email journals.permissions@oup.com.

        - - - - diff --git a/app/src/main/assets/pages/5_treatment_of_current_(active)_disease_therapy__g__antiretroviral_therapy_(art)_and_treatment_of_persons.html b/app/src/main/assets/pages/5_treatment_of_current_(active)_disease_therapy__g__antiretroviral_therapy_(art)_and_treatment_of_persons.html deleted file mode 100644 index a09cfad..0000000 --- a/app/src/main/assets/pages/5_treatment_of_current_(active)_disease_therapy__g__antiretroviral_therapy_(art)_and_treatment_of_persons.html +++ /dev/null @@ -1,278 +0,0 @@ - - - - - - - - Antiretroviral Therapy (ART) and Treatment of HIV Seropositive Patients with Active Tuberculosis - - - - - - - - -
        - -

        Treatment of persons living with HIV with active TB disease should be carried out in consultation with a - physician - who has experience in the use of rifamycin drugs and antiretroviral agents. Recommendations on the treatment of - TB - in combination with antiretroviral therapy continue to evolve, and it is important to check for updated - guidelines: - https://aidsinfo.nih.gov/guidelines

        - -

        Antiretroviral therapy (ART) improves outcomes for persons living with HIV and decreases HIV-related mortality. - Patients in the United States with tuberculosis disease who are HIV co-infected commonly have advanced HIV/AIDS - with - low CD4 counts and high plasma HIV RNA levels; all TB patients with HIV co-infection should receive treatment - for - HIV with ART.

        - -

        Timing of ART

        - -

        Multiple studies have demonstrated the benefits of ART initiation among people living with HIV during TB - treatment, - including a reduction in mortality. However, the use of ART among persons living with HIV with active TB disease - is - complicated by overlapping toxicity profiles of some antituberculosis and antiretroviral drugs; complex - drug-drug - interactions; and the occurrence of ‘paradoxical” or immune reconstitution inflammatory syndrome (IRIS). There - are - certain situations where ART therapy should be delayed. A study of people living with HIV with TB meningitis - found - that early ART was associated with an increase in severe adverse events and no mortality benefit. Thus, timing - of - ART initiation in HIV-TB patients should take into account both the degree of immune suppression and site of - disease - (see Table 16). Patients who are already on ART at the time of TB diagnosis, generally should be continued on - the - ART treatment (though ART regimen may need to be adjusted).

        - -

        Choice of ART

        - -

        Because of the potential for significant drug interactions and overlapping toxicities, the choice of ART among - persons living with HIV who have active TB disease should be made only after direct communication between HIV - and - tuberculosis care providers. Any change in either the TB medications or the ART regimen should be immediately - shared - between the 2 providers.

        - -

        There are clinically important drug-drug interactions between the rifamycins (e.g., rifampin, rifabutin) and some - of - the antiretroviral drugs, especially integrase and protease inhibitors. The rifamycins are inducers of the - cytochrome P450-3A (CYP3A) system in the liver and thereby decrease serum concentrations of drugs metabolized by - this system including integrase and protease inhibitors. Rifampin is a potent inducer of the CYP3A, while - rifabutin - is a less potent inducer. Rifampin cannot be given with most protease inhibitors because it results in low serum - levels of these drugs. Rifabutin has less of an effect and therefore can be used with certain protease - inhibitors as - described below. Rifampin and rifabutin can be given with certain integrase inhibitors.

        - -

        The protease inhibitors also affect rifamycin metabolism and because the rifamycin metabolism is retarded by - these - drugs, the dose of rifabutin needs to be reduced in order to avoid rifabutin related toxicity.

        - -

        Despite these drug-drug interactions, a rifamycin (rifampin or rifabutin) should ALWAYS be included in the - treatment - regiment for drug susceptible TB among persons living with HIV.

        - -

        Rifampin can be given with the following antiretrovirals: -

          -
        • MOST Nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs) (e.g.,zidovudine, lamivudine, - emtricitabine, - tenofovir disoproxil fumarate (TDF), abacavir). Tenofovir alafenamide (TAF) is not currently recommended for - use - in combination with rifamycins. -
          • -
        • SELECTED Non-nucleoside reverse transcriptase inhibitors (NNRTIs): efavirenz only (all others are - contraindicated for coadministration with rifampin). -
          • -
        • Selected Integrase inhibitors: raltegravir and dolutegravir. The dose of raltegravir must be increased to - 800 mg - bis in die (twice daily) (BID) and dose of dolutegravir must be increased to 50 mg BID for patients on - rifampin. - Neither drug requires a dosing change when used with rifabutin. -
          • -
        -

        - -

        Rifampin should NOT be used with the following: -

          -
        • Tenofoviral afenamide(TAF)
          • -
        • Protease inhibitors
          • -
        • Nevirapine, etravirine, rilpivarine (NNRTIs)
          • -
        • Bictegravir, elvitegravir
          • -
        - A summary of preferred treatment options for patients with tu- berculosis disease who are HIV infected is shown in - Table 18 and Table 19. For additional information refer to updated HHS guidelines, visit: https://aidsinfo.nih.gov/guidelines -

        - -

        Table 16. When to start HIV therapy

        - - - - - - - - - - - - - - - - - - - - - - - -
        HHS Panel Recommendations on treatment of Tuberculosis Disease with HIV co-infection: Timing of Antiretroviral Therapy (ART) Initiation relative to TB treatment
        CD4 count and/or clinical status at time of TB diagnosisART Initiation
        < 50 cells/mm3**within 2 weeks of starting TB therapy.
        > 50 cells/mm3**by 8 to 12 weeks of starting TB therapy
        Pregnant, any CD4 countAs early as feasible
        - -

        ** EXCEPTION: tuberculous meningitis. To avoid life-threatening CNS immune reconstitution inflammatory syndrome - (IRIS), persons living with HIV and tuberculous meningitis should not be started on ART until AFTER 8 weeks of - TB - therapy

        - -

        Above based on guidelines developed by the Department of Health and Human Services (DHHS) Panel on Guidelines for - Use - of Antiretroviral Agents for Adults and Adolescents and Use of Antiretroviral Drugs in Pregnant Women with HIV - Infection and Interventions to Reduce Perinatal Transmission in the United States, last reviewed and updated - April - 15, 2019 (https://aidsinfo.nih.gov/guidelines).

        - -

        Table 17. What to start: Choice of TB therapy and Antiretroviral Therapy (ART) when treating co-infected - patients

        - - - - - - - - - - - - - - - - - - - - - - - -
        Principle: Despite drug interactions, a rifamycin (rifampin or rifabutin) should be included in TB - regimens for patients receiving ART, with dosage adjustment if necessary (see Table SMR11 for dosage - adjustments). -
        Option 1: Rifabutin-based - ART regimen: Integrase inhibitor and 2 NRTIs - Preferred ART choices: RAL or DTG + TDF/FTC - Alternative ART choices: DTG + ABC/3TC - Contraindicated medications: TAF, other integrase inhibitors (Bictegravir, Elvitegravir) - NOTE: Dolutegravir has higher barrier to resistance compared to raltegravir. Dolutegravir is - preferred when there is high risk poor adherence. -
        Option 2: Rifampin-based ART regimen: Efavirenz and 2 NRTIs Preferred ART choices: Efavirenz (NNRTI) + (TDF/FTC) Alternative ART choices: Efavirenz + ABC/3TC Contraindicated medications: TAF, other NNRTIs: Nevaripine, Doravirine, Etravirine, or Rilpivirine NOTE: Efavirenz is not a preferred regimen for patients initiating ART. Integrase inhibitors DTG and RAL are preferred ART regimens for patients initiating ART but require BID dosing if used with rifampin. Efavirenz has low barrier to resistance making this regimen less suitable when there is high risk for poor adherence. Efavirenz is associated with neuropsychiatric side-effects. Screening for depression and suicidality is recommended prior to and during efavirenz-based regimens. - Efavirenz + ABC/3TC is associated with higher rates of virologic failure when baseline HIV viral load is >100.000 copies/ml. -
        Option 3: Rifabutin-based (dose adjusted) - ART regimen: boosted PI and 2 NRTIs - Preferred ART choices: ATV/r or ATV/c + TDF/FTC - DRV/r or DRV/c + TDF/FTC Alternative ART choices: ABC/3TC in place of TDF/FTC Contraindicated medications: TAF NOTE: PI’s have high barrier to resistance. However, given rifabutin is given at half-dose when used - with PI’s adherence to ART should be closely monitored. Poor adherence to PI’s while on rifabutin increases risk for rifampin resistance. -
        Option 4: Rifampin-based - ART regimen: dose adjusted integrase inhibitor + 2 NRTIs - Preferred ART choices: RAL (dose adjusted) or DTG (dose adjusted)+ TDF/FTC Alternative ART choices: - DTG (dose adjusted) + ABC/3TC - Contraindicated medications: TAF, other integrase inhibitors (Bictegravir, Elvitegravir) - NOTE: Dolutegravir has higher barrier to resistance compared to raltegravir. Dolutegravir is - preferred when there is high risk poor adherence. -
        Choice for Pregnant women with active TB and HIV infection: - TB regimen: Rifabutin –based (dose adjusted) - ART regimen: boosted PI (ARV/r or DRV/r) 2 + 2 NRTIs (TDF/FTC or ABC/3TC) - NOTE: Preliminary data suggest that there is an increased risk of neural tube defects in infants - born to women who were receiving DTG at the time of conception. DTG is contraindicated for pregnant - women during first trimester and for women who are planning to become pregnant or are not using - effective contraception. DTG is the preferred integrase inhibitor after first trimester 1. -
        - -
          -
        • NRTIs: nucleoside/-tide reverse transcriptase inhibitors
          • -
        • NNRTIs: non-nucleoside reverse transcriptase inhibitors
          • -
        • PIs: protease inhibitors
          • -
        • /r: boosted with ritonavir
          • -
        • /c: boosted with cobicistat
          • -
        • TDF: Tenofovir disoproxil fumarate
          • -
        • TAF: Tenofovir alafenamide
          • -
        • FTC: Emtricitabine
          • -
        • 3TC: Lamivudine
          • -
        • ABC: Abacavir
          • -
        • ATV/r: Atazanavir/ritonavir
          • -
        • DRV/r: Daraunavir/ritonavir
          • -
        • RAL: Raltegravir
          • -
        • DTG: Dolutegravir
          • -
        - -

        Above based on guidelines developed by the Department of Health and Human Services (DHHS) Panel on Guidelines for - Use - of Antiretroviral Agents for Adults and Adolescents and Use of Antiretroviral Drugs in Pregnant Women with HIV - Infection and Interventions to Reduce Perinatal Transmission in the United States, last reviewed and updated - April - 15, 2019 (http://aidsinfo.nih.gov/guidelines).

        - -

        1-Data on integrase inhibitors and pregnancy outcomes is rapidly evolving and DHHS guidelines are frequently - updated.

        - -

        2-Cobicistat is currently not recommended for pregnant women.

        - -

        Table 18. Dosage Adjustments for ART and Rifamycins when used in Combination

        - - -

        *Preliminary data suggest that there is an increased risk of neural tube defects in infants born to women who - were - receiving DTG at the time of conception. DTG is contraindicated for pregnant women during first trimester and - for - women who are planning to become pregnant or are not using effective contraception. DTG is the preferred - integrase - inhibitor after first trimester.

        - -
          -
        • NNRTIs: non-nucleoside reverse transcriptase inhibitors
          • -
        • PIs: protease inhibitors
          • -
        • ATV/r: Atazanavir/ritonavir
          • -
        • DRV/r: Daraunavir/ritonavir
          • -
        • LPV/r: Lopinavir/ritonavir
          • -
        • RAL: Raltegravir
          • -
        • DTG: Dolutegravir
          • -
        • /c : boosted with cobicistat
          • -
        - -

        Table 18 is based on guidelines developed by the Department of Health and Human Services (DHHS) Panel on - Guidelines - for Use of Antiretroviral Agents for Adults and Adolescents and Use of Antiretroviral Drugs in Pregnant Women - with - HIV Infection and Interventions to Reduce Perinatal Transmission in the United States, last reviewed and updated - April 15, 2019 - (aidsinfo.nih.gov/guidelines)

        - -

        1-Data on integrase inhibitors and pregnancy outcomes is rapidly evolving and DHHS - guidelines are frequently updated.

        - -

        2-Cobicistat is currently not recommended for pregnant women.

        - -
        - - - - diff --git a/app/src/main/assets/pages/5_treatment_of_current_(active)_disease_therapy__h__immune_reconstitution_inflammatory_syndrome.html b/app/src/main/assets/pages/5_treatment_of_current_(active)_disease_therapy__h__immune_reconstitution_inflammatory_syndrome.html index 4dafdf8..87bce48 100644 --- a/app/src/main/assets/pages/5_treatment_of_current_(active)_disease_therapy__h__immune_reconstitution_inflammatory_syndrome.html +++ b/app/src/main/assets/pages/5_treatment_of_current_(active)_disease_therapy__h__immune_reconstitution_inflammatory_syndrome.html @@ -15,33 +15,47 @@
        - -

        The temporary exacerbation of TB symptoms and lesions after initiation of antituberculosis therapy—known as a +

        +
        +
        +
        + +
        +

        V. Treatment of Current (Active) Disease Therapy

        +
        +

        Last Updated October 2025

        +
        +
        +
        +

        The temporary exacerbation of TB symptoms and lesions after initiation of antituberculosis therapy—known as a paradoxical reaction or immune reconstitution inflammatory syndrome (IRIS) —has been described as a rare occurrence - in HIV-negative patients after the initiation of antituberculosis therapy. These “paradoxical reactions” are - thought - to be due to immune reconstitution and can occur among persons living with HIV who are started on antiretroviral - therapy early in the course of antituberculosis therapy. After initial clinical improvement, paradoxical - worsening - of disease (or IRIS) developed in up to 36% of HIV infected TB patients on ART compared with 7% of HIV - coinfected - patients treated for TB but who did not receive ART [Narita et al.].

        + in HIV-negative patients after the initiation of antituberculosis therapy. +

        +

        + These “paradoxical reactions” are thought to be due to immune reconstitution and can occur among persons living with + HIV who are started on antiretroviral therapy early in the course of antituberculosis therapy. Features of IRIS include + fever, recurrent symptoms, lymphadentitis, and worsening pulmonary infiltrates on chest radiographs. +

        +

        + After initial clinical improvement, paradoxical worsening of disease (or IRIS) developed in up to 18 of patients (range 4 to 54%) + in a pooled estimate derived from 40 observational studies (Ultman OA et al, Ann Intern Med 2015; 10:1077-99). TB-associated IRIS is + associated with significant morbidity and even mortality; up to 25% of patients with this syndrome are hospitalized.

        -

        Paradoxical or immune reconstitution manifestations depend on anatomical site of disease (e.g., headache in +

        Paradoxical or immune reconstitution manifestations depend on anatomical site of disease (e.g., headache in patient with meningeal TB). Additionally, IRIS can occur in an anatomical site of known disease and/or anatomical sites not previously known to be involved (e.g., lymph node suppuration in patient without previous adenopathy), a - process - known as “unmasking”. Of note, patients with HIV can have > 1 opportunistic infection and unmasking reactions + process known as “unmasking”.

        +

        Of note, patients with HIV can have > 1 opportunistic infection and unmasking reactions can occur that are from previously unsuspected infections (e.g., cryptococcal meningitis). The paradoxical reactions are associated with increased reactivity on tuberculin skin testing and a significant reduction in HIV viral load.

        -

        IRIS may be self-limited and can last 10 to 40 days. Mild to moderate reactions can be managed by reassurance and +

        IRIS may be self-limited and can last 10 to 40 days. Mild to moderate reactions can be managed by reassurance and nonsteroidal anti-inflammatory drugs. Severe reactions included those characterized by marked increase in adenopathy causing an anatomic problem (e.g., compromised breathing, swallowing or movement of the neck, or expanding @@ -51,10 +65,17 @@ ART) starting at a dose of prednisone at 1.25—1.5 mg/kg per day for 2 weeks and then tapering the therapy over a period of 6 to 12 weeks (or longer).

        -

        For persons living with HIV with active TB disease and at high risk for developing TB-associated immune - reconstitution inflammatory syndrome (TB-IRIS), pre-emptive prednisone is now rec- ommended as adjunctive - therapy - with the initiation of antiretroviral therapy. “High-risk” for IRIS is defined as CD4 count ≤ 100 cells/mm3 and +

        + A randomized controlled trial of prednisone (1.5 mg/kg per day for two weeks and then 0.75 mg/kg per day for 2 weeks) vs placebo for persons with HIV and active TB disease who developed moderate to severe IRIS (persons with life threatening IRIS were excluded) + +demonstrated that prednisone reduced the need (or duration) of hospitalization and facilitated improvements in symptoms, performance and quality of life (Meintjes G et al. AIDS 2010; 24:2381-90). +

        + +

        For persons living with HIV with active TB disease and at high risk for developing TB-associated immune reconstitution inflammatory syndrome (TB-IRIS), pre-emptive prednisone is now recommended as adjunctive therapy with the initiation of antiretroviral therapy + (Meintjes G et al. New Engl J Med 2018; 379:1915-25). + +

        +

        “High-risk” for IRIS is defined as CD4 count ≤ 100 cells/mm3 and starting ART within 30 days of initiating treatment for active TB. The prednisone regimen consists of 40 mg daily for 2 weeks followed by 20 mg daily for 2 weeks. Preemptive prednisone therapy for IRIS prevention should NOT be diff --git a/app/src/main/assets/pages/5_treatment_of_current_(active)_disease_therapy__i__treatment_of_extrapulmonary_tb.html b/app/src/main/assets/pages/5_treatment_of_current_(active)_disease_therapy__i__treatment_of_extrapulmonary_tb.html index 78bbdea..dd64a51 100644 --- a/app/src/main/assets/pages/5_treatment_of_current_(active)_disease_therapy__i__treatment_of_extrapulmonary_tb.html +++ b/app/src/main/assets/pages/5_treatment_of_current_(active)_disease_therapy__i__treatment_of_extrapulmonary_tb.html @@ -15,27 +15,34 @@

        +
        +
        +
        +
        + +
        +

        V. Treatment of Current (Active) Disease Therapy

        +
        +

        Last Updated October 2025

        +
        +
        +
        -

        The basic principles that underlie the treatment of pulmonary TB also apply to extrapulmonary forms of the - disease. A - 6-month course of therapy is recommended for treating tuberculosis involving any site with the exception of the - meninges for which a 9 – to 12-month regimen is recommended. Prolongation of therapy also should be considered - for - patients with tuberculosis in any site that is slow to respond. The addition of corticosteroids is recommended - for - patients with meningitis as it decreases mortality as discussed below.

        +

        + The basic principles that underlie the treatment of pulmonary TB also apply to extrapulmonary forms of the disease. A 6-month course of therapy is recommended for treating tuberculosis involving any site with the exception of the meninges for which a 9 – to 12-month regimen is recommended. Prolongation of therapy also should be considered for patients with tuberculosis in any site that is slow to respond. The addition of corticosteroids is recommended for patients with TB meningitis as it is associated with a decrease in mortality as discussed below. +

        -

        Lymphatic and hematogenous TB are especially common among persons with HIV infection. Central nervous system +

        Lymphatic and hematogenous TB are especially common among persons with HIV infection. Central nervous system involvement has been reported and may be difficult to diagnose when it occurs in conjunction with other opportunistic CNS infections.

        -

        To establish the diagnosis of extrapulmonary TB, a variety of specimens including pleural fluid, peritoneal +

        To establish the diagnosis of extrapulmonary TB, a variety of specimens including pleural fluid, peritoneal fluid, pleural and peritoneal biopsy specimens, lymph node tissue, bone marrow, bone, blood, urine, brain, or cerebrospinal fluid may need to be obtained for mycobacterial culture.

        -

        Specimens must be examined microscopically and sent for AFB culture, but the inability to demonstrate AFB on +

        Specimens must be examined microscopically and sent for AFB culture, but the inability to demonstrate AFB on smear and the absence of granuloma formation does not exclude the diagnosis of TB. Surgery may be necessary to obtain specimens for diagnosis and to treat such processes as constrictive pericarditis or spinal cord compression from diff --git a/app/src/main/assets/pages/5_treatment_of_current_(active)_disease_therapy__j__adjunctive_use_of_corticosteroid_therapy.html b/app/src/main/assets/pages/5_treatment_of_current_(active)_disease_therapy__j__adjunctive_use_of_corticosteroid_therapy.html index d702dd2..2363aab 100644 --- a/app/src/main/assets/pages/5_treatment_of_current_(active)_disease_therapy__j__adjunctive_use_of_corticosteroid_therapy.html +++ b/app/src/main/assets/pages/5_treatment_of_current_(active)_disease_therapy__j__adjunctive_use_of_corticosteroid_therapy.html @@ -16,20 +16,44 @@

        -

        Adjunct corticosteroid therapy is indicated in the treatment of - tuberculous meningitis as its use along with appropriate antituberculosis drugs is associated with a lower - mortality. For patients with tuberculous meningitis, dexamethasone or prednisolone is recommended for a total of 6 - to 8 weeks. An initial dose of 8 mg per day of dexamethasone for children < 25 kg and 12 mg per day for children > - 25 kg and adults can be used. The initial dose is given for 3 weeks and then the dose should be tapered during the - following 3 weeks. Adjunctive corticosteroids in treatment of pericardial tuberculosis did not reduce mortality, - tamponade or constrictive physiology in a large randomized clinical trial and are thus no longer routinely - recommended. Some experts would use corticosteroids in selected patients with TB pericarditis: those with large - effusions and/or high levels of inflammation in pericardial fluid.

        +
        +
        +
        +
        + +
        +

        V. Treatment of Current (Active) Disease Therapy

        +
        +

        Last Updated October 2025

        +
        +
        +
        + +

        Adjunct corticosteroid therapy is indicated in the treatment of tuberculous meningitis⌃

        +
        +
          +
        • + As its use along with appropriate antituberculosis drugs is associated with a lower mortality. +
          • +
        • + For patients with tuberculous meningitis, dexamethasone or prednisolone is recommended as adjunct therapy for a total of 6 to 8 weeks. An initial dose of 8 mg per day of dexamethasone for children < 25 kg and 12 mg per day for children > 25 kg and adults can be used. The initial dose is given for 3 weeks and then the dose should be tapered during the following 3 weeks. +
          • +
        • + Adjunctive corticosteroids in treatment of pericardial tuberculosis did not reduce mortality, tamponade or constrictive physiology in a large randomized clinical trial and are thus no longer routinely recommended. +
          • +
        • + Some experts would use corticosteroids in selected patients with TB pericarditis: those with large effusions and/or high levels of inflammation in pericardial fluid. +
          • +
        +
        -

        Table 19. Guidelines for Treatment of Extrapulmonary* Tuberculosis: Length of therapy and Adjunctive Use of + +

        Table 19. Guidelines for Treatment of Extrapulmonary* Tuberculosis: Length of therapy and Adjunctive Use of Corticosteroids

        - + +
        +
        @@ -115,14 +139,15 @@

        Table 19. Guidelines for Treatment of Extrapulmonary* Tuberculo

        -
        Site
        - -

        *ALWAYS EVALUATE for concomitant pulmonary involvement with respiratory samples for smear and culture (regardless of - chest imaging findings).

        - -

        Based on CID 2016:63 (1 October) • Nahid et al

        + +
        +

        + 2 mg/kg prednisone daily over three weeks, followed by taper Maximum dose 60 mg
        OR
        + Dexamethasone 0.3-0.6 mg/kg daily over three weeks, followed by taper Round to nearest tablet size (2, 4, 6 mg) Maximum dose 12 mg +

        + diff --git a/app/src/main/assets/pages/6_pregnancy_and_tb.html b/app/src/main/assets/pages/6_pregnancy_and_tb.html index ba6fe3c..3133a22 100644 --- a/app/src/main/assets/pages/6_pregnancy_and_tb.html +++ b/app/src/main/assets/pages/6_pregnancy_and_tb.html @@ -16,9 +16,21 @@
        -

        List of Subchapters

        +
        +
        +
        +
        + +
        +

        VI. Pregnancy and TB

        +
        +

        Last Updated October 2025

        +
        +
        +
        +

        List of Subchapters

        -
          +
          • Treatment for LTBI and Risk Factors
          • Treatment of Active TB in Pregnancy
            • diff --git a/app/src/main/assets/pages/6_pregnancy_and_tb__a__treatment_for_ltbi_and_risk_factors.html b/app/src/main/assets/pages/6_pregnancy_and_tb__a__treatment_for_ltbi_and_risk_factors.html index 9b752d9..d4f5a8c 100644 --- a/app/src/main/assets/pages/6_pregnancy_and_tb__a__treatment_for_ltbi_and_risk_factors.html +++ b/app/src/main/assets/pages/6_pregnancy_and_tb__a__treatment_for_ltbi_and_risk_factors.html @@ -15,69 +15,128 @@
            - -

            Screening for LTBI

            -

            Testing asymptomatic patients for latent TB infection (LTBI) during pregnancy is indicated only for pregnant patients with - significant risk factors for progression to active TB disease during pregnancy. High risk individuals are defined in - Targeted Testing and Diagnostic Tests for LTBI, including Table 3. This includes:

            -
              -
            • Those with recent contact with a patient with untreated active pulmonary TB)
              • -
            • Persons living with HIV who are not on antiretroviral therapy (ART) and those with CD4 count ≤200 cells/mm3
              • -
            • Patients with other significant immunocompromising conditions or on immunosuppressive medications
              • -
            -

            Diagnostic evaluation after positive diagnostic test for LTBI. Pregnant patients with a new positive diagnostic test +

            +
            +
            +
            + +
            +

            VI. Pregnancy and TB

            +
            +

            Last Updated October 2025

            +
            +
            +
            + +

            Screening for LTBI

            +

            Testing asymptomatic patients for latent TB infection (LTBI) during pregnancy is indicated only for pregnant patients with + significant risk factors for progression to active TB disease during pregnancy. +

            + High risk individuals are defined in + Targeted Testing and Diagnostic Tests for LTBI, including Table 3. This includes: ⌃ +
            +
              +
            • Those with recent contact with a patient with untreated active pulmonary TB)
              • +
            • Persons living with HIV who are not on antiretroviral therapy (ART) and those with CD4 count ≤200 cells/mm3
              • +
            • Patients with other significant immunocompromising conditions or on immunosuppressive medications
              • +
            +
            + Diagnostic evaluation after positive diagnostic test for LTBI⌃ +
            +

            Pregnant patients with a new positive diagnostic test for LTBI (i.e., tuberculin skin test [TST] or Interferon-γ release assay [IGRA]) must undergo clinical evaluation to rule out active TB. This includes evaluation for TB-related symptoms (e.g., fever, cough, weight loss), physical exam, and a chest - radiograph (a lead apron should cover the entire abdomen during the chest radiograph) regardless of gestational age. Some + radiograph (a lead apron should cover the entire abdomen during the chest radiograph) regardless of gestational age.

            +

            Some defer the chest radiograph until after the first trimester if the patient has no symptoms. Patients in whom there is a suspicion - for active TB disease should be further evaluated as discussed in Section IV. Laboratory Diagnosis of Active Tuberculosis. - Pregnant patients with active TB disease should be treated without delay as outlined below. Patients with a positive diagnostic - test for LTBI (TST or IGRA) with no evidence of active TB may be presumed to have latent TB and should be managed as discussed below.

            -

            Clinical manifestations. Persons (including those who are pregnant) with LTBI are asymptomatic and not contagious. There is no risk for + for active TB disease should be further evaluated as discussed in Section IV. Laboratory Diagnosis of Active Tuberculosis.

            +

            + Pregnant patients with active TB disease should be treated without delay as outlined below.

            +

            + Patients with a positive diagnostic + test for LTBI (TST or IGRA) with no evidence of active TB may be presumed to have latent TB and should be managed as discussed below.

            +
            + Clinical manifestations⌃ +
            +

            Persons (including those who are pregnant) with LTBI are asymptomatic and not contagious. There is no risk for vertical transmission of LTBI from mother to fetus.

            +
            -

            Treatment of LTBI in Pregnancy.

            -

            Timing of treatment.

            -
              -
            • The potential of adverse effects associated with LTBI treatment during pregnancy must be weighed against the potential risks of progression to active TB during pregnancy.
              • -
            • Pregnant women diagnosed with LTBI prior to pregnancy and started on treatment for LTBI for an appropriate indication should continue LTBI treatment during pregnancy; - the regimen should be modified if necessary (e.g., 3HP is not recommended during pregnancy for the treatment of LTBI because of lack of data on its use in this setting).
              • -
            • For many persons who are pregnant, not severely immunocompromised, and have LTBI, delay of treatment of LTBI until three months after delivery is recommended as discussed below.
              • -
            -

            For patients with significant immunocompromise (excluding HIV infection), the decision to treat during pregnancy or defer until after delivery should be based on individual clinical - circumstances including the degree of immunocompromise. For those with significant immunocompromised status (e.g., organ transplantation, receiving a biologic agent, immunocompromising - drugs such as prednisone >15 mg/d [or equivalent] for more than 1 month) treatment of LTBI during pregnancy is recommended.

            -

            Persons living with HIV who are pregnant. The management of LTBI among pregnant women living with HIV depends on whether there was recent exposure to a patient with untreated active TB, - as well as the HIV infection management status.

            +

            Treatment of LTBI in Pregnancy.

            + Timing of treatment.⌃ +
            +
              +
            • The potential of adverse effects associated with LTBI treatment during pregnancy must be weighed against the potential risks of progression to active TB during pregnancy.
              • +
            • Pregnant women diagnosed with LTBI prior to pregnancy and started on treatment for LTBI for an appropriate indication should continue LTBI treatment during pregnancy; + the regimen should be modified if necessary (e.g., 3HP is not recommended during pregnancy for the treatment of LTBI because of lack of data on its use in this setting).
              • +
            • For many persons who are pregnant, not severely immunocompromised, and have LTBI, delay of treatment of LTBI until three months after delivery is recommended as discussed below.
              • +
            +
            + For patients with significant immunocompromise (excluding HIV infection)⌃ +
            +
            • the decision to treat during pregnancy or defer until after delivery should be based on individual clinical + circumstances including the degree of immunocompromise.
              • +
            • For those with significant immunocompromised status (e.g., organ transplantation, receiving a biologic agent, immunocompromising + drugs such as prednisone >15 mg/d [or equivalent] for more than 1 month) treatment of LTBI during pregnancy is recommended.
            +
            + +

            Persons living with HIV who are pregnant.

            + + The management of LTBI among pregnant women living with HIV depends on whether there was recent exposure to a patient with untreated active TB, + as well as the HIV infection management status. ⌃ +
            +
              +
            • Recent Exposure/LTBI. Treatment is recommended for all persons living with HIV (regardless of CD4 count) diagnosed with LTBI who are pregnant with recent exposure to a patient with + untreated active respiratory TB given the increased risk of progression to active TB in such cases.
              • +
            • Persons living with HIV not on antiretroviral therapy. Treatment of LTBI is recommend for those who are pregnant and living with HIV if they are not on antiretroviral therapy. + Antiretroviral therapy should be started in this group.
              • +
            • For pregnant women living with HIV on antiretroviral therapy with CD4 count ≤350 cells/mm3, LTBI treatment during pregnancy is recommended given increased risk of progression + to active TB. The CD4 cutoff for LTBI therapy is somewhat controversial; some experts favor a lower threshold (e.g., CD4 count ≤200 cells/mm3).
              • +
            • For those pregnant persons living with HIV with a CD4 count >350 cells/mm3m, LTBI therapy should be deferred until three months after delivery.
              • +
            +
            + The recommendation to defer LTBI therapy until three months after delivery is based on the results of a clinical trial (N Engl J Med 2019; 381:1333) demonstrating more frequent adverse + pregnancy outcomes among patients in high TB incidence settings treated with isoniazid during pregnancy than among patients treated three months after delivery. ⌃ +
              -
            • Recent Exposure/LTBI. Treatment is recommended for all persons living with HIV (regardless of CD4 count) diagnosed with LTBI who are pregnant with recent exposure to a patient with - untreated active respiratory TB given the increased risk of progression to active TB in such cases.
              • -
            • Persons living with HIV not on antiretroviral therapy. Treatment of LTBI is recommend for those who are pregnant and living with HIV if they are not on antiretroviral therapy. - Antiretroviral therapy should be started in this group.
              • -
            • For pregnant persons living with HIV on antiretroviral therapy with CD4 count ≤350 cells/mm3, LTBI treatment during pregnancy is recommended given increased risk of progression - to active TB. The CD4 cutoff for LTBI therapy is somewhat controversial; some experts favor a lower threshold (e.g., CD4 count ≤200 cells/mm3).
              • -
            • For those pregnant persons living with HIV with a CD4 count >350 cells/mm3m, LTBI therapy should be deferred until three months after delivery.
              • -
            -

            The recommendation to defer LTBI therapy until three months after delivery is based on the results of a clinical trial (N Engl J Med 2019; 381:1333) demonstrating more frequent adverse - pregnancy outcomes among patients in high TB incidence settings treated with isoniazid during pregnancy than among patients treated three months after delivery. The study included +

          • The study included 956 pregnant women living with HIV (CD4 count 351 to 670 cells/mm3 on antiretroviral thearpy) randomly assigned to initiate LTBI treatment with isoniazid immediately or defer - treatment until 12 weeks after delivery. Study subjects were excluded if in the first trimester of pregnancy or if they had recent TB exposure; mothers and infants were followed - for 48 weeks after delivery. The incidence of TB was comparable between the groups (0.60 versus 0.59 per 100 person-years). However, the composite adverse pregnancy outcome + treatment until 12 weeks after delivery.
            • + +
          • Study subjects were excluded if in the first trimester of pregnancy or if they had recent TB exposure; mothers and infants were followed + for 48 weeks after delivery.
            • +
          • The incidence of TB was comparable between the groups (0.60 versus 0.59 per 100 person-years).
            • + +
          • However, the composite adverse pregnancy outcome (stillbirth or spontaneous abortion, low birth weight, preterm delivery, or congenital anomalies) was more commonly seen among those in the immediate LTBI treatment group compared to - the deferred group (23.6% versus 17.0%). The rate of hepatotoxicity was similar between the groups (6.2 versus 7.2 percent). The US Department of Health and Human Services (DHHS) guidelines - recommend delaying LTBI treatment among pregnant persons living with HIV until three months after delivery in the absence of a recent TB exposure, but do not specify a CD4 threshold.

            -

            Recent TB infection. For any pregnant woman with documented recent LTBI (e.g., exposure to a patient with untreated active pulmonary TB and documented recent infection based on an LTBI - diagnostic test) or recent (within two years) conversion of a diagnostic test for TB infection to positive, LTBI treatment is recommended with one of three regimens mentioned below.

            -

            HIV-uninfected Pregnant Women. For pregnant women without HIV infection who are not severely immunocompromised and have no recent exposure to a person with untreated active respiratory TB, - it is recommended that LTBI treatment be deferred until three months after delivery, to minimize the risk of drug-induced hepatitis (e.g., from isoniazid) and adverse pregnancy outcomes - associated with LTBI treatment during pregnancy. In such cases, close follow-up is required. For all pregnant persons with LTBI who have therapy deferred until three months after delivery, - a follow-up evaluation for active TB disease (including chest radiograph) to confirm that active TB did not develop in the interval since diagnosis of LTBI and the time that treatment for LTBI - begins should be carried out.

            -

            Selecting an LTBI treatment regimen. The same treatment regimens for LTBI that are used in non-pregnant persons can be used in pregnant and postpartum women with the EXCEPTION that 3HP - (isoniazid plus rifapentine given weekly x 12 weeks) should NOT be used in pregnant and postpartum women because of lack of data in these settings. Options for CDC recommended LTBI regimens - in pregnant and postpartum women include rifampin (for four months), isoniazid plus rifampin for 3 months, or isoniazid for 6-9 months. All pregnant persons receiving isoniazid for LTBI - should also receive pyridoxine (vitamin B6) 50 mg po daily.

            + the deferred group (23.6% versus 17.0%).
            • +
          • The rate of hepatotoxicity was similar between the groups (6.2 versus 7.2 percent).
            • +
          +
        +

        The US Department of Health and Human Services (DHHS) guidelines + recommend delaying LTBI treatment among pregnant persons living with HIV until three months after delivery in the absence of a recent TB exposure, but do not specify a CD4 threshold.

        + Recent TB infection⌃ +
        +
          +
        • For any pregnant woman with documented recent LTBI (e.g., exposure to a patient with untreated active pulmonary TB and documented recent infection based on an LTBI + diagnostic test) or recent (within two years) conversion of a diagnostic test for TB infection to positive, LTBI treatment is recommended with one of three regimens mentioned below.
        +
        + HIV-uninfected Pregnant Women.⌃ +
        +
          +
        • For pregnant women without HIV infection who are not severely immunocompromised and have no recent exposure to a person with untreated active pulmonary (or laryngeal) TB, it is recommended that LTBI treatment be deferred until three months after delivery, to minimize the risk of drug-induced hepatitis (e.g., from isoniazid) and adverse pregnancy outcomes associated with LTBI treatment during pregnancy. In such cases, close follow-up is required.
          • +
        • For all pregnant persons with LTBI who have therapy deferred until three months after delivery, a follow-up evaluation for active TB disease (including chest radiograph) to confirm that active TB did not develop in the interval since diagnosis of LTBI and the time that treatment for LTBI begins should be carried out.
        +
        + Selecting an LTBI treatment regimen⌃ +
        +
        • + The same treatment regimens for LTBI that are used in non-pregnant persons can be used in pregnant and postpartum women with the EXCEPTION that 3HP (isoniazid plus rifapentine given weekly x 12 weeks) should NOT be used in pregnant and postpartum women because of lack of data in these settings. +
          • +
        • Options for CDC recommended LTBI regimens in pregnant and postpartum women include rifampin (for four months), isoniazid plus rifampin for 3 months, or isoniazid for 6-9 months. All pregnant persons receiving isoniazid for LTBI should also receive pyridoxine (vitamin B6) 50 mg po daily.
        + + + diff --git a/app/src/main/assets/pages/6_pregnancy_and_tb__b__treatment_of_active_tb_in_pregnancy.html b/app/src/main/assets/pages/6_pregnancy_and_tb__b__treatment_of_active_tb_in_pregnancy.html index 7ec512e..1df08d8 100644 --- a/app/src/main/assets/pages/6_pregnancy_and_tb__b__treatment_of_active_tb_in_pregnancy.html +++ b/app/src/main/assets/pages/6_pregnancy_and_tb__b__treatment_of_active_tb_in_pregnancy.html @@ -15,16 +15,27 @@
        - -

        - TB disease discovered during pregnancy should be treated without delay. Because of the risk - for tuberculosis to the fetus, treatment of TB in pregnant women should be initiated whenever the - probability of maternal disease is moderate to high. Three sputum samples should be submitted for - examination. The outcome of the cultures and susceptibility test results will determine the regimen for - continuation of treatment.

        -
          -
        • Drug Treatment in - Pregnancy +
          +
          +
          +
          + +
          +

          VI. Pregnancy and TB

          +
          +

          Last Updated October 2025

          +
          +
          +
          +

          + TB disease discovered during pregnancy should be treated without delay. Because of + the risk for tuberculosis to the fetus, treatment of TB in pregnant women should be initiated whenever + the probability of maternal disease is moderate to high. A minimum of two sputum samples should be submitted + for examination. The outcome of the AFB cultures and drug susceptibility test results will determine the regimen for continuation of treatment.

          +
            +
          1. Drug Treatment in + Pregnancy⌃
            2. +
            • The initial treatment regimen usually consists of INH, RIF and EMB; consideration should be given to including PZA.
              • @@ -39,15 +50,16 @@ pregnant women because of potential adverse effects on the fetus. Fluoroquinolones (e.g., levofloxacin, moxifloxacin) have been associated with arthropathies in young animals; therefore, they should be avoided if possible in pregnant women.
            - -
          2. Breast Feeding +
            3. +
          3. Breast Feeding⌃
            4. +

            The small concentrations of first line TB drugs in breast milk do not have a toxic effect on nursing newborns and breast feeding should not be discouraged. Conversely, drugs in breast milk should not be considered to serve as effective treatment for disease or as treatment of LTBI in a nursing infant.

            - -
        -

        Table 20. Use of Anti-TB Medications in Special Situations:
        Pregnancy, Tuberculous Meningitis +

        + +

        Table 20. Use of Anti-TB Medications in Special Situations:
        Pregnancy, Tuberculous Meningitis and Renal Failure

        @@ -135,16 +147,15 @@

        Table 20. Use of Anti-TB Medications in Special Situations:
        Do Not Use: Associated with premature labor, congenital malformations or teratogenicity.

        NOTES: Table 20 Special Situations

        -

        (1) As - with all medications given during pregnancy, anti-TB drugs should be used with caution. The risk of TB to the - fetus far outweighs the risk of medications. Pregnant patients with active TB should be treated. Data are - limited on the safety of some anti-TB drugs during pregnancy. Table 20 presents a consensus of published data - and recommendations. Although detailed teratogenic data is not available, PZA can probably be used safely for - pregnant patients. Concentrations of anti-TB drugs in breast milk are low; treatment with these medications is - not a contraindication to breastfeeding. (Conversely, medication present in breast milk is not sufficient to - prevent or treat TB in the newborn.) Consult a medical expert when treating a pregnant patient who has TB. For - treatment of LTBI, most authorities recommend beginning INH several months after delivery, unless the woman is - at high risk for progression to active TB (e.g., recent TST or IGRA conversion, HIV-infected).

        +

        (1) As with all medications given during pregnancy, anti-TB drugs should be used with caution. The risk of TB to + the fetus far outweighs the risk of medications. Pregnant patients with active TB should be treated. Data are limited + on the safety of some anti-TB drugs during pregnancy. Table 20 presents a consensus of published data and recommendations. + Although detailed teratogenic data is not available, PZA can probably be used safely for pregnant patients. Concentrations + of anti-TB drugs in breast milk are low; treatment with these medications is not a contraindication to breastfeeding. + Conversely, medication present in breast milk is not sufficient to prevent or treat TB in the newborn. Consult a + medical expert when treating a pregnant patient who has TB. For treatment of LTBI, most authorities recommend beginning + INH 3 months after delivery (as discussed in the text), unless the woman is at high risk for progression to active TB (e.g., + recent infection as evidenced by being a close contact of an infectious TB case, recent TST or IGRA conversion, HIV-infected with CD4<350).

        (2) Steroid treatment appears to improve outcome in TB meningitis, particularly in patients with altered mental status.

        (3) If possible, monitor serum drug levels of patients with renal insufficiency. See page 71 for dosage.

        @@ -156,4 +167,7 @@

        Table 20. Use of Anti-TB Medications in Special Situations:
        + + + diff --git a/app/src/main/assets/pages/7_childhood_tuberculosis.html b/app/src/main/assets/pages/7_childhood_tuberculosis.html index be6b962..099dfaa 100644 --- a/app/src/main/assets/pages/7_childhood_tuberculosis.html +++ b/app/src/main/assets/pages/7_childhood_tuberculosis.html @@ -16,13 +16,25 @@
        -

        The basic +

        +
        +
        +
        + +
        +

        VII. Childhood Tuberculosis

        +
        +

        Last Updated October 2025

        +
        +
        +
        +

        The basic principles for treatment of TB disease and infection in children and adolescents are similar to adults. The objective of treatment is to kill the tuberculous bacilli in the shortest amount of time while preventing the development of resistance. Dosage adjustments of medications may often be required based on weight. When possible, crushed tablets or the mixed contents of capsules are preferred over suspensions that may be difficult to access and may contain fewer desirable additives.

        -

        Either TST +

        Either TST or immunologic-based testing (IGRAs) may be used to aid in LTBI or TB disease diagnosis in immune competent children age 2 years or older. For children under 2 years of age, TST is preferred; however, if the child has a negative TST but is at high risk for TB disease or LTBI, then an IGRA may be performed. The involvement of a @@ -30,7 +42,7 @@ guiding diagnostic evaluation and treatment.

        -
          +
          • A. Management Considerations
            • diff --git a/app/src/main/assets/pages/7_childhood_tuberculosis__a__management_considerations.html b/app/src/main/assets/pages/7_childhood_tuberculosis__a__management_considerations.html index 2645a01..5dc8b24 100644 --- a/app/src/main/assets/pages/7_childhood_tuberculosis__a__management_considerations.html +++ b/app/src/main/assets/pages/7_childhood_tuberculosis__a__management_considerations.html @@ -5,7 +5,7 @@ - Management + Management Considerations @@ -15,68 +15,66 @@
            - -
              +
              +
              +
              +
              + +
              +

              VII. Childhood Tuberculosis

              +
              +

              Last Updated October 2025

              +
              +
              +
              +
              • TB disease in infants and children younger than 4 years of age is much more likely to disseminate; therefore, prompt evaluation and treatment should be started when the diagnosis is suspected.
                • -
              • Mycobacterial culture of respiratory specimens for children with suspected pulmonary TB is recommended. - Acceptable specimens include induced sputa or early morning gastric aspirates on - 3 consecutive days for children who cannot produce sputa. In cases when the adult source case is known, it - is - acceptable to rely on the results of susceptibility tests of specimens from the adult source case to guide - the - treatment regimen. However, when the M. tuberculosis isolate from the presumed source patient is not - available or in cases of suspected drug-resistant TB, obtaining induced sputa or early morning gastric - aspirates - from the young child should be performed. In certain situations, bronchoalveolar lavage or tissue biopsy may - be considered. +
              • Performing Mycobacterial culture, smear and nucleic acid antigen tests from respiratory + specimens of children with suspected pulmonary TB is generally recommended, particularly + when the source patient is unknown or there is concern for drug-resistant TB. Acceptable + specimens include induced sputa or early morning gastric aspirates on 3 consecutive days + for children who cannot produce sputa. . In certain situations, bronchoalveolar lavage or + tissue biopsy may be considered. If the adult source case is known, it may be reasonable to + rely on the results of susceptibility tests of specimens from the adult source case to guide + the pediatric treatment regimen, particularly if the child is well, the sole reason for + evaluation is contact investigation, and obtaining pediatric specimens is technically challenging or burdensome. +
                • + +
              • Children 3 months-15 years of age with non-severe pulmonary TB (including intrathoracic TB) should receive an empiric + regimen of four drugs (INH, RIF, PZA, EMB) for 2 months and RIF and INH for the remaining 2 months when + drug resistance is not suspected (4 months total). A three-drug regimen (INH, RIF, PZA) can be used as empiric + therapy when the isolate (i.e. from source TB case) is known to be fully drug susceptible. Non-severe pulmonary + TB is defined as AFB smear-negative disease with the following radiographic features: uncomplicated hilar + adenopathy without evidence of airway obstruction, disease confined to less than one whole lobe, without complex pleural effusion, miliary pattern, or cavitary lesion.
                • -
              • Primary - intrathoracic TB (parenchymal infiltration, hilar adenopathy, or both, in a child with evidence of - tuberculosis - exposure) should be treated in the same manner as pulmonary TB. +
              • + Children who are severely ill, have a history of prematurity <37 weeks, are <3 months or >/=16 years of age, are + pregnant, who have underlying disease that could complicate interpretation of the response to TB therapy, or + who have a contraindication to any first line TB medication are not currently candidates for a 4- month treatment regimen.
                • -
              • An empiric regimen of four drugs (INH, RIF, PZA, EMB) for 2 months and RIF and INH for the remaining 4 - months when - the possibility of drug resistance is low is recommended. A three-drug regimen (INH, RIF, PZA) can be used - as - initial therapy when the isolate (i.e., from source TB case) is known to be fully drug susceptible. Children - and - adolescents with “adult-type” tuberculosis consisting of cavitation and AFB positive sputum samples should - receive a 4-drug regimen initially until susceptibility is proven. The persistence of cavitary lesions - and/or a - positive sputum culture after 2 months of therapy may warrant extension to a 9-month course of therapy. +
              • + Children with severe pulmonary TB, or who otherwise do not meet criteria for non-severe disease treatment, should receive an additional 2 months of RIF and INH, for a minimum duration of 6 months of therapy. Children and adolescents with “adult-type” tuberculosis consisting of cavitation and AFB positive sputum samples should receive a 4-drug regimen initially until susceptibility is proven. The persistence of cavitary lesions and/or a positive sputum culture after 2 months of effective therapy may warrant extension to a 9-month course of therapy.
                • -
              • 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 as a fourth drug, even in children too young for routine eye testing. - Streptomycin, - kanamycin or amikacin can also be used as a fourth drug when necessary. Either an aminoglycoside or - ethionamide should be used as the fourth drug in cases of TB meningitis. +
              • In general, non-CNS extrapulmonary TB can be treated with the same regimen as pulmonary TB (i.e. 4- 6 months for drug-susceptible disease). Drug-susceptible peripheral lymph node TB is considered non-severe and can be treated for 4 months. All other disease forms should be treated for a minimum of 6 months.
                • -
              • In general, extrapulmonary TB, including cervical adenopathy (scrofula), can be treated with the same - regimen as - pulmonary TB (i.e., 6 months for drug-susceptible disease). Exceptions include TB meningitis for which 12 - months of therapy is currently recommended. +
              • Children with TB meningitis should receive 12 months of therapy.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 as a fourth drug, even in children too young for routinevisual testing. Ethionamide should be used instead of ethambutol in cases of TB meningitis. Streptomycin, kanamycin or amikacin can be used as alternatives, if necessary, though should generally be avoided based on their significant toxicity profile. Directly observed therapy is the standard of care for all children.
                • -
              • Directly observed therapy is the standard of care for all children. HIV testing should be performed on all - individuals with TB disease (including children) as the treatment regimen (including need for antiretroviral - therapy) is altered with HIV infection. +
              • + HIV testing should be performed on all individuals with TB disease (including children) as the treatment regimen (including need for antiretroviral therapy) may need to be altered in people with HIV infection.
                • -
              • Clinical and radiographic examinations may be monitored for response to therapy. However, resolution of - abnormal - findings on chest radiography with pulmonary or intrathoracic lymphadenopathy may lag behind clinical - response. Chest radiography is usually not performed at the conclusion of a successful course of treatment - and - should not be used as a criterion for discontinuing anti-TB drugs. +
              • + Clinical and radiographic examinations may be monitored for response to therapy. However, resolution of abnormal findings on chest radiography with pulmonary or intrathoracic lymphadenopathy may lag behind clinical response. Chest radiography is usually not performed at the conclusion of a successful course of treatment and should not be used as a criterion for discontinuing anti-TB drugs.
              • Management of the newborn infant whose mother or other caregiver is suspected of having TB is based on individual considerations. Separation of the mother (or caregiver) and infant should be minimized, if - possible. Differing circumstances and resulting - recommendations are as follows: + possible.
                • + +
              • Differing circumstances and resulting + recommendations are as follows:⌃
                • +
                • Mother or other caregiver who has a positive tuberculin skin test or IGRA and normal chest radiography. @@ -115,18 +113,42 @@ therapy can be documented and is no longer infectious, the infant’s INH may be discontinued.
                +
              -

              For a - mother/caregiver who has active TB disease and is infectious, the mother/caregiver and infant should be - separated until the mother/caregiver and infant have received appropriate anti-tuberculosis therapy. The +

            • For a + mother/caregiver who has active TB disease and is infectious,⌃
              • +
              + +
            • + + the mother/caregiver and infant should be + separated until the mother/caregiver and infant have received appropriate anti-tuberculosis therapy. + +
              • +
            • + The mother/caregiver should wear a mask and follow appropriate infection control procedures until she/ he has been - judged to be noninfectious. The mother/caregiver should be separated from the infant in situations where + judged to be noninfectious. +
              • + +
            • + The mother/caregiver should be separated from the infant in situations where infection with MDR TB is possible and/or adherence to therapy cannot be documented. BCG immunization may be - considered for the infant in these situations. Women with tuberculosis disease who have received 2 weeks of - appropriate therapy and who are not considered to be infectious may breastfeed. A healthcare provider with + considered for the infant in these situations.
              • + +
            • + Women with tuberculosis disease who have received 2 weeks of + appropriate therapy and who are not considered to be infectious may breastfeed.
              • + +
            • + A healthcare provider with expertise in tuberculosis should be consulted to assist with recommendations in individual situations when a - woman receiving antituberculosis therapy wishes to provide human milk to an infant.

              + woman receiving antituberculosis therapy wishes to provide human milk to an infant.
              • +
            + + + diff --git a/app/src/main/assets/pages/8_tuberculosis_and_long-term_care_facilities.html b/app/src/main/assets/pages/8_tuberculosis_and_long-term_care_facilities.html index 1a1ab8c..5e333a5 100644 --- a/app/src/main/assets/pages/8_tuberculosis_and_long-term_care_facilities.html +++ b/app/src/main/assets/pages/8_tuberculosis_and_long-term_care_facilities.html @@ -15,6 +15,18 @@
            +
            +
            +
            +
            + +
            +

            VIII. Tuberculosis and Long-Term Care Facilities

            +
            +

            Last Updated June 2024

            +
            +
            +

            TB remains a problem in older individuals who may have been infected many years ago and did not develop active disease at the time. Also, there is increasing documentation of outbreaks of TB occurring in nursing home diff --git a/app/src/main/assets/pages/8_tuberculosis_and_long_term_care_facilities.html b/app/src/main/assets/pages/8_tuberculosis_and_long_term_care_facilities.html index df12f5b..810f5f3 100644 --- a/app/src/main/assets/pages/8_tuberculosis_and_long_term_care_facilities.html +++ b/app/src/main/assets/pages/8_tuberculosis_and_long_term_care_facilities.html @@ -5,7 +5,7 @@ - GA TB Reference Guide + Tuberculosis and Long-Term Care Facilities @@ -15,28 +15,43 @@

            -

            - TB remains a problem in older individuals who may have been infected many years ago and did not develop active - disease at the time. Also, there is increasing documentation of outbreaks of TB occurring in nursing home - residents when a patient with TB disease infects a population of older people who are newly exposed to that - case.

            -

            - TB control in nursing homes and long-term care facilities must begin with a careful assessment of TB status upon - admission, including a diagnostic test for LTBI (TST or IGRA). For those with a positive diagnostic test for - LTBI, an assessment and chest x-ray should be performed as described above to exclude active TB disease.

            -

            - Since people over 50 years old may have diminished skin test reactivity, the two-step technique (see page 10) of +

            +
            +
            +
            + +
            +

            Tuberculosis and Long-Term Care Facilities

            +
            +

            Last Updated June 2024

            +
            +
            +
            +

            + TB remains a problem in older individuals who may have been infected many years ago and did not develop active + disease at the time. Also, there have been outbreaks of TB occurring in nursing home residents when a patient + with active TB disease infects a population of older people who are newly exposed to that case.

            +

            + TB prevention and control in nursing homes and long-term care facilities must begin with a careful assessment + of TB status upon admission, including a diagnostic test for LTBI (TST or IGRA). For those with a positive + diagnostic test for LTBI, an assessment and chest x-ray should be performed as described above to exclude active TB disease.

            +

            + Since people over 50 years old may have diminished skin test reactivity, the two-step technique (see Two-Step Testing) of tuberculin skin testing is recommended upon admission to the nursing home if the TST is the diagnostic test being performed to screen for LTBI. A “booster effect” with the TST has been noted in elderly persons in whom - the delayed type hypersensitivity (DTH) reaction to tuberculin may have waned over the years. In these + the delayed type hypersensitivity (DTH) reaction to tuberculin may have waned over the years. +

            +

            + In these situations, an initial tuberculin skin test may demonstrate a negative reaction, but it boosts the immune system so that subsequent tuberculin skin tests may be increased in size and may be interpreted as positive. This “boosted” response is considered as the valid baseline for the individual and thought to represent latent TB infection (after active disease is excluded).

            -

            - Residents of nursing homes or long-term care facilities whose baseline two-step skin tests are negative (or + + Residents of nursing homes or long-term care facilities whose baseline two-step skin tests are negative (or whose baseline IGRA is negative if the IGRA is being used to screen for LTBI) on admission should have repeat - testing performed when an exposure to a case of potentially infectious TB has occurred.

            + testing performed when an exposure to a case of potentially infectious TB has occurred.⌃ +
            • Any person who converts a TST or IGRA from negative to positive should be considered for treatment of LTBI after active TB is ruled out (by chest x-ray at a minimum and sputum specimen if @@ -47,15 +62,16 @@
            • Treatment of active TB disease (Class III) is the same as that used for younger adults.
            -

            - Employees of nursing homes or long-term care facilities should have two-step tuberculin testing when they start - to work in the nursing home if the TST is used for testing of health care workers (if they have not had a TST in - the year prior to initiating employment). The frequency of subsequent testing of healthcare workers is - described on page 102. Employees who are TST (or IGRA) positive at baseline should be evaluated for treatment of - LTBI (see pages 25—27). In addition, those with a recent TST conversion should be strongly encouraged to take - treatment for LTBI after active TB is excluded. Routine annual symptom screening for previously positive TST - employees is recommended instead of an annual CXR.

            +
            +

            + Employees of nursing homes or long-term care facilities should have two-step tuberculin testing when they start to work in the nursing home if the TST is used for testing of health care workers (if they have not had a TST in the year prior to initiating employment). The frequency of subsequent testing of healthcare workers is described on page 102.

            +

            + Employees who have a positive LTBI diagnostic test at baseline should be evaluated for treatment of LTBI (see pages 25—27). In addition, those with a recent LTBI diagnostic test conversion should be ncouraged to take treatment for LTBI after active TB disease is excluded. Routine annual symptom screening for health care workers with a previously positive diagnostic test for LTBI (TST or IGRA) is recommended instead of an annual CXR. +

            + + + diff --git a/app/src/main/assets/pages/9_bcg_vaccination.html b/app/src/main/assets/pages/9_bcg_vaccination.html index e4b4e9c..2f64dd5 100644 --- a/app/src/main/assets/pages/9_bcg_vaccination.html +++ b/app/src/main/assets/pages/9_bcg_vaccination.html @@ -15,19 +15,41 @@
            -

            +

            +
            +
            +
            + +
            +

            IX. BCG Vaccination

            +
            +

            Last Updated October 2025

            +
            +
            +
            +

            Bacille Calmette-Guerin (BCG) vaccine is one of the most commonly used vaccines in the world and is given in - the vast majority of low- and middle-income countries. BCG is recommended in higher TB incidence areas because + the vast majority of low- and middle-income countries.

            + +

            BCG is recommended in higher TB incidence areas because it has a documented protective effect against TB meningitis and disseminated TB in young children. It does not prevent primary infection and, more importantly, does not prevent reactivation of latent pulmonary infection, - the principal source of bacillary spread in the community. The impact of BCG vaccination on + the principal source of bacillary spread in the community. +

            +

            The impact of BCG vaccination on transmission of M. tuberculosis is therefore very limited (or there is no impact). BCG has not impacted the global epidemiology of TB. Because of variable efficacy, BCG is NOT recommended for use in the U.S. - BCG is not a contraindication to a TST but as noted there can be cross reactions between BCG and the TST. - The primary advantage of IGRAs is that they do not cross react with BCG. Interpretation of a tuberculin skin - test reaction is not changed for patients who have received BCG. A reaction of > 10 mm (> - 5mm in HIV-infected persons) of induration should be considered infection with M. tuberculosis because: +

            + +

            + BCG is not a contraindication to a TST but as noted there can be cross reactions between BCG and the TST. + The primary advantage of IGRAs is that they do not cross react with BCG. Interpretation of a tuberculin skin + test reaction is not changed for patients who have received BCG.

            + + A reaction of > 10 mm (> + 5mm in HIV-infected persons) of induration should be considered infection with M. tuberculosis because:⌃ +
            • Conversion rates after BCG vaccination are not 100%;
            • The mean reaction size among BCG vaccines are often less than 10 mm (a large reaction is more @@ -38,7 +60,8 @@ reaction is from infection, not vaccination.
            -

            +

            +

            Since many BCG-vaccinated persons come from areas of high TB incidence, it is important that persons with a positive TST be evaluated for presence of TB disease and managed accordingly. Appropriate follow-up includes a careful medical history, CXR to rule out active TB disease, and evaluation for treatment of LTBI. An IGRA is the @@ -47,4 +70,7 @@

            + + + diff --git a/app/src/main/assets/pages/fig1_factors_to_be_considered.html b/app/src/main/assets/pages/fig1_factors_to_be_considered.html index 42abcba..3e65d8b 100644 --- a/app/src/main/assets/pages/fig1_factors_to_be_considered.html +++ b/app/src/main/assets/pages/fig1_factors_to_be_considered.html @@ -13,7 +13,18 @@ - +
            +
            +
            +
            + +
            +

            Factors to be considered in deciding to initiate treatment empirically for active tuberculosis (TB) (prior to microbiologic confirmation)

            +
            +

            Last Updated October 2025

            +
            +
            +
            Figure 1

            Figure 1. Factors to be considered in deciding to initiate treatment empirically for active tuberculosis (TB) (prior to microbiologic confirmation)

            diff --git a/app/src/main/assets/pages/ic_chapter.svg b/app/src/main/assets/pages/ic_chapter.svg new file mode 100644 index 0000000..338eedd --- /dev/null +++ b/app/src/main/assets/pages/ic_chapter.svg @@ -0,0 +1,4 @@ + + + + diff --git a/app/src/main/assets/pages/main.js b/app/src/main/assets/pages/main.js new file mode 100644 index 0000000..0c499a6 --- /dev/null +++ b/app/src/main/assets/pages/main.js @@ -0,0 +1,77 @@ +// function to handle tab switching for any table +function activateTab(tableContainer, tabIndex) { + if (!tableContainer) return; + + tableContainer.querySelectorAll('.tab-button, .tab, .tab, .tab').forEach(tab => { + tab.classList.remove('active-option', 'active-tab'); + }); + + tableContainer.querySelectorAll('.option-content, .tab-content, .tab-content, .tab-content').forEach(content => { + content.classList.remove('active-option', 'active-tab'); + }); + + // Add active class to selected tab and content + const selectedTab = tableContainer.querySelectorAll('.tab-button, .tab, .tab, .tab')[tabIndex]; + const selectedContent = tableContainer.querySelectorAll('.option-content, .tab-content, .tab-content, .tab-content')[tabIndex]; + + if (selectedTab) { + if (selectedTab.classList.contains('tab')) { + selectedTab.classList.add('active-tab'); + } else if (selectedTab.classList.contains('tab-button')) { + selectedTab.classList.add('active-option'); + } else if (selectedTab.classList.contains('tab')) { + selectedTab.classList.add('active-tab'); + } else if (selectedTab.classList.contains('tab')) { + selectedTab.classList.add('active-tab'); + } + } + + if (selectedContent) { + if (selectedContent.classList.contains('tab-content')) { + selectedContent.classList.add('active-tab'); + } else if (selectedContent.classList.contains('option-content')) { + selectedContent.classList.add('active-option'); + } else if (selectedContent.classList.contains('tab-content')) { + selectedContent.classList.add('active-tab'); + } else if (selectedContent.classList.contains('tab-content')) { + selectedContent.classList.add('active-tab'); + } + } +} + +// Function to handle tab switching with event +function handleTabSwitch(event, tabIndex) { + // Get the clicked button from the event + const clickedButton = event.currentTarget; + + const tableContainer = clickedButton.closest('.uk-overflow-auto'); + if (!tableContainer) return; + + // Get all tab buttons in this container + const tabButtons = tableContainer.querySelectorAll('.tab-button, .tab, .tab, .tab'); + + // Find the index of the clicked button within its container + const clickedIndex = Array.from(tabButtons).indexOf(clickedButton); + + // Generate a unique ID for the container if it doesn't have one + if (!tableContainer.id) { + tableContainer.id = 'table-' + Math.random().toString(36).substr(2, 9); + } + + // Switch to the correct tab + activateTab(tableContainer, clickedIndex); +} + +function switchTab(tabIndex, event) { + handleTabSwitch(event, tabIndex); +} + +// For Dropdown Togglers +function toggleItem(clickedTitle) { + const itemContent = clickedTitle.nextElementSibling; + + itemContent.classList.toggle('active'); + + const chevronUp = clickedTitle.querySelector('.chevron-up'); + chevronUp.classList.toggle('active'); +} \ No newline at end of file diff --git a/app/src/main/assets/pages/privacy_policy.html b/app/src/main/assets/pages/privacy_policy.html deleted file mode 100644 index 26d6256..0000000 --- a/app/src/main/assets/pages/privacy_policy.html +++ /dev/null @@ -1,397 +0,0 @@ - - - - - - - - GA TB Reference Guide Privacy Policy - - - - - - -
            - -
            - Last updated March 08, 2021 -

            Thank you for choosing to be part of our community at Georgia Clinical & Translational Science Alliance - ("Company," - "we," "us," or "our"). We are committed to protecting your personal information and your - right to privacy. If - you - have any questions or concerns about this privacy notice or our practices with regard to your personal - information, - please contact us at morgan.greenleaf@emory.edu.

            - -

            - This privacy notice describes how we might use your information if you: -

              -
            • Download and use our mobile application — Georgia TB Reference Guide
              • -
            • Engage with us in other related ways ― including any sales, marketing, or events
              • -
            - - - In this privacy notice, if we refer to:
            -

            - - -
              -
            • "App," we are referring to any application of ours that references or links to this policy, including - any listed - above -
              • -
            • "Services," we are referring to our App, and other related services, including any sales, marketing, - or events -
              • -
            -

            - The purpose of this privacy notice is to explain to you in the clearest way possible what information we - collect, - how we use it, and what rights you have in relation to it. If there are any terms in this privacy notice that - you do - not agree with, please discontinue use of our Services immediately. -

            - -

            Please read this privacy notice carefully, as it will help you understand what we do with the information that - we - collect.

            - -

            TABLE OF CONTENTS

            - -
              -
            1. WHAT INFORMATION DO WE COLLECT?
              2. -
            2. HOW DO WE USE YOUR INFORMATION?
              3. -
            3. WILL YOUR INFORMATION BE SHARED WITH ANYONE?
              4. -
            4. HOW LONG DO WE KEEP YOUR INFORMATION?
              5. -
            5. HOW DO WE KEEP YOUR INFORMATION SAFE?
              6. -
            6. DO WE COLLECT INFORMATION FROM MINORS?
              7. -
            7. WHAT ARE YOUR PRIVACY RIGHTS?
              8. -
            8. CONTROLS FOR DO-NOT-TRACK FEATURES
              9. -
            9. DO CALIFORNIA RESIDENTS HAVE SPECIFIC PRIVACY RIGHTS?
              10. -
            10. DO WE MAKE UPDATES TO THIS NOTICE?
              11. -
            11. HOW CAN YOU CONTACT US ABOUT THIS NOTICE?
              12. -
            12. HOW CAN YOU REVIEW, UPDATE OR DELETE THE DATA WE COLLECT FROM YOU?
              13. -
            - - -

            1. WHAT INFORMATION DO WE COLLECT?

            -

            Personal information you disclose to us

            - -

            In Short: We collect personal information that you provide to us.

            - -

            We collect personal information that you voluntarily provide to us when you express an interest in obtaining - information about us or our products and Services, when you participate in activities on the App or otherwise - when you contact us.

            -

            - The personal information that we collect depends on the context of your interactions with us and the App, the - choices you make and the products and features you use. The personal information we collect may include the - following:

            - -

            All personal information that you provide to us must be true, complete and accurate, and you must notify us of - any changes to such personal information.

            - -

            Information automatically collected

            - - In Short: Some information — such as your Internet Protocol (IP) address and/or browser and device - characteristics — is collected automatically when you visit our App. - -

            We automatically collect certain information when you visit, use or navigate the App. This information does not - reveal your specific identity (like your name or contact information) but may include device and usage - information, such as your IP address, browser and device characteristics, operating system, language - preferences, referring URLs, device name, country, location, information about how and when you use our App and - other technical information. This information is primarily needed to maintain the security and operation of our - App, and for our internal analytics and reporting purposes.

            - -

            The information we collect includes:

            -
              -
            • Log and Usage Data. Log and usage data is service-related, diagnostic, usage and performance - information our - servers automatically collect when you access or use our App and which we record in log files. Depending on - how you interact with us, this log data may include your IP address, device information, browser type and - settings and information about your activity in the App (such as the date/time stamps associated with your - usage, pages and files viewed, searches and other actions you take such as which features you use), device - event information (such as system activity, error reports (sometimes called 'crash dumps') and hardware - settings). -
              • - -
            • - Device Data. We collect device data such as information about your computer, phone, tablet or other - device - you use to access the App. Depending on the device used, this device data may include information such as - your IP address (or proxy server), device and application identification numbers, location, browser type, - hardware model Internet service provider and/or mobile carrier, operating system and system configuration - information. -
              • - -
            • Location Data. We collect location data such as information about your device's location, which can - be either precise or imprecise. How much information we collect depends on the type and settings of the - device you use to access the App. For example, we may use GPS and other technologies to collect geolocation - data that tells us your current location (based on your IP address). You can opt out of allowing us to - collect - this information either by refusing access to the information or by disabling your Location setting on your - device. Note however, if you choose to opt out, you may not be able to use certain aspects of the Services. -
              • -
            - - -

            Information collected through our App

            -

            In Short: We collect information regarding your mobile device, push notifications, when you use our - App.

            - -

            If you use our App, we also collect the following information:

            - -
              -
            • Mobile Device Access. We may request access or permission to certain features from your mobile device, - including your mobile device's calendar, microphone, and other features. If you wish to change our access or - permissions, you may do so in your device's settings. -
              • -
            • Mobile Device Data. We automatically collect device information (such as your mobile device ID, model and - manufacturer), operating system, version information and system configuration information, device and - application identification numbers, browser type and version, hardware model Internet service provider - and/or mobile carrier, and Internet Protocol (IP) address (or proxy server). If you are using our App, we - may also collect information about the phone network associated with your mobile device, your mobile - device’s operating system or platform, the type of mobile device you use, your mobile device’s unique device - ID and information about the features of our App you accessed. -
              • -
            • Push Notifications. We may request to send you push notifications regarding your account or certain features - of the App. If you wish to opt-out from receiving these types of communications, you may turn them off in - your device's settings. -
              • -
            - -

            This information is primarily needed to maintain the security and operation of our App, for troubleshooting and - for - our internal analytics and reporting purposes.

            - -

            2. HOW DO WE USE YOUR INFORMATION?

            - -

            In Short: We process your information for purposes based on legitimate business interests, the - fulfillment of our - contract with you, compliance with our legal obligations, and/or your consent.

            - -

            - We use personal information collected via our App for a variety of business purposes described below. We process - your personal information for these purposes in reliance on our legitimate business interests, in order to enter - into or perform a contract with you, with your consent, and/or for compliance with our legal obligations. We - indicate the specific processing grounds we rely on next to each purpose listed below.

            - -

            We use the information we collect or receive:

            - -
              -
            • For other business purposes. We may use your information for other business purposes, such as data analysis, - identifying usage trends, determining the effectiveness of our promotional campaigns and to evaluate and - improve our App, products, marketing and your experience. We may use and store this information in - aggregated and anonymized form so that it is not associated with individual end users and does not include - personal information. -
              • -
            • Research
              • -
            - - -

            3. WILL YOUR INFORMATION BE SHARED WITH ANYONE?

            - -

            In Short: We only share information with your consent, to comply with laws, to provide you with - services, to protect - your rights, or to fulfill business obligations.

            - -

            We may process or share your data that we hold based on the following legal basis:

            - -
              -
            • Consent: We may process your data if you have given us specific consent to use your personal information for - a specific purpose. -
              • -
            • Legitimate Interests: We may process your data when it is reasonably necessary to achieve our legitimate - business interests. -
              • -
            • Performance of a Contract: Where we have entered into a contract with you, we may process your personal - information to fulfill the terms of our contract. -
              • -
            • Legal Obligations: We may disclose your information where we are legally required to do so in order to - proceeding, court order, or legal process, such as in response to a court order or a subpoena (including in - response to public authorities to meet national security or law enforcement requirements). -
              • -
            • Vital Interests: We may disclose your information where we believe it is necessary to investigate, prevent, - or take action regarding potential violations of our policies, suspected fraud, situations involving - potential threats to the safety of any person and illegal activities, or as evidence in litigation in which - we are involved. -
              • -
            -

            More specifically, we may need to process your data or share your personal information in the following - situations:

            -
              -
            • Business Transfers. We may share or transfer your information in connection with, or during negotiations of, - any merger, sale of company assets, financing, or acquisition of all or a portion of our business to another - company. -
              • -
            • Affiliates. We may share your information with our affiliates, in which case we will require those - affiliates to honor this privacy notice. Affiliates include our parent company and any subsidiaries, joint - venture partners or other companies that we control or that are under common control with us. -
              • -
            • Business Partners. We may share your information with our business partners to offer you certain products, - services or promotions. -
              • -
            - -

            4. HOW LONG DO WE KEEP YOUR INFORMATION?

            - -

            In Short: We keep your information for as long as necessary to fulfill the purposes outlined in this - privacy notice - unless otherwise required by law.

            - - - We will only keep your personal information for as long as it is necessary for the purposes set out in this privacy - notice, unless a longer retention period is required or permitted by law (such as tax, accounting or other legal - requirements). No purpose in this notice will require us keeping your personal information for longer than 2 years. - - When we have no ongoing legitimate business need to process your personal information, we will either delete or - anonymize such information, or, if this is not possible (for example, because your personal information has been - stored - in backup archives), then we will securely store your personal information and isolate it from any further - processing - until deletion is possible. - -

            5. HOW DO WE KEEP YOUR INFORMATION SAFE?

            - - In Short: We aim to protect your personal information through a system of organizational and technical security - measures. - -

            We have implemented appropriate technical and organizational security measures designed to protect the security - of - any - personal information we process. However, despite our safeguards and efforts to secure your information, no - electronic - transmission over the Internet or information storage technology can be guaranteed to be 100% secure, so we - cannot - promise or guarantee that hackers, cybercriminals, or other unauthorized third parties will not be able to - defeat - our - security, and improperly collect, access, steal, or modify your information. Although we will do our best to - protect - your personal information, transmission of personal information to and from our App is at your own risk. You - should - only - access the App within a secure environment.

            - -

            6. DO WE COLLECT INFORMATION FROM MINORS?

            - -

            In Short: We do not knowingly collect data from or market to children under 18 years of age.

            - - -

            We do not knowingly solicit data from or market to children under 18 years of age. By using the App, you - represent - that - you are at least 18 or that you are the parent or guardian of such a minor and consent to such minor dependent’s - use - of - the App. If we learn that personal information from users less than 18 years of age has been collected, we will - deactivate the account and take reasonable measures to promptly delete such data from our records. If you become - aware - of any data we may have collected from children under age 18, please contact us at - morgan.greenleaf@emory.edu.

            - -

            7. WHAT ARE YOUR PRIVACY RIGHTS?

            -

            In Short: You may review, change, or terminate your account at any time.

            - -

            If you are a resident in the EEA or UK and you believe we are unlawfully processing your personal information, - you - also - have the right to complain to your local data protection supervisory authority. You can find their contact - details - here: - https://ec.europa.eu/justice/data-protection/bodies/authorities/index_en.htm.

            - -

            If you are a resident in Switzerland, the contact details for the data protection authorities are available - here: - https://www.edoeb.admin.ch/edoeb/en/home.html. -

            -

            8. CONTROLS FOR DO-NOT-TRACK FEATURES

            - -

            Most web browsers and some mobile operating systems and mobile applications include a Do-Not-Track ("DNT") - feature - or - setting you can activate to signal your privacy preference not to have data about your online browsing - activities - monitored and collected. At this stage no uniform technology standard for recognizing and implementing DNT - signals - has - been finalized. As such, we do not currently respond to DNT browser signals or any other mechanism that - automatically - communicates your choice not to be tracked online. If a standard for online tracking is adopted that we must - follow - in - the future, we will inform you about that practice in a revised version of this privacy notice. -

            -

            9. DO CALIFORNIA RESIDENTS HAVE SPECIFIC PRIVACY RIGHTS?

            - -

            In Short: Yes, if you are a resident of California, you are granted specific rights regarding access - to your - personal - information.

            - -

            - California Civil Code Section 1798.83, also known as the "Shine The Light" law, permits our users who are - California - residents to request and obtain from us, once a year and free of charge, information about categories of - personal - information (if any) we disclosed to third parties for direct marketing purposes and the names and addresses of - all - third parties with which we shared personal information in the immediately preceding calendar year. If you are a - California resident and would like to make such a request, please submit your request in writing to us using the - contact - information provided below.

            - -

            If you are under 18 years of age, reside in California, and have a registered account with the App, you have the - right - to request removal of unwanted data that you publicly post on the App. To request removal of such data, please - contact - us using the contact information provided below, and include the email address associated with your account and - a - statement that you reside in California. We will make sure the data is not publicly displayed on the App, but - please - be - aware that the data may not be completely or comprehensively removed from all our systems (e.g. backups, etc.). -

            -

            10. DO WE MAKE UPDATES TO THIS NOTICE?

            - -

            In Short: Yes, we will update this notice as necessary to stay compliant with relevant laws.

            - -

            We may update this privacy notice from time to time. The updated version will be indicated by an updated - "Revised" - date - and the updated version will be effective as soon as it is accessible. If we make material changes to this - privacy - notice, we may notify you either by prominently posting a notice of such changes or by directly sending you a - notification. We encourage you to review this privacy notice frequently to be informed of how we are protecting - your - information. -

            -

            11. HOW CAN YOU CONTACT US ABOUT THIS NOTICE?

            -

            If you have questions or comments about this notice, you may email us at morgan.greenleaf@emory.edu or by post - to:

            -
            - Georgia Clinical & Translational Science Alliance
            - 1440 Clifton Rd NE #134
            - Atlanta, GA 30322
            - United States - -
            - -

            12. HOW CAN YOU REVIEW, UPDATE, OR DELETE THE DATA WE COLLECT FROM YOU?

            - -

            Based on the applicable laws of your country, you may have the right to request access to the personal - information - we - collect from you, change that information, or delete it in some circumstances. To request to review, update, or - delete - your personal information, please submit a request form by clicking here.

            -

            This privacy policy was created using Termly's Privacy Policy Generator.

            - -
            - -
            - - - - diff --git a/app/src/main/assets/pages/table_10_pediatric_dosages_rifampin_in_children_(birth_to_15_years).html b/app/src/main/assets/pages/table_10_pediatric_dosages_rifampin_in_children_(birth_to_15_years).html index 11662c3..35b71a7 100644 --- a/app/src/main/assets/pages/table_10_pediatric_dosages_rifampin_in_children_(birth_to_15_years).html +++ b/app/src/main/assets/pages/table_10_pediatric_dosages_rifampin_in_children_(birth_to_15_years).html @@ -4,7 +4,7 @@ - + GA TB Reference Guide @@ -15,7 +15,9 @@
            -

            View in chapter -> Special Clinical Situations

            +

            View in chapter → Special Clinical Situations

            +

            Last Updated October 2025

            +

        diff --git a/app/src/main/assets/pages/table_11_pediatric_dosages_ethambutol_in_children_(birth_to_15_years).html b/app/src/main/assets/pages/table_11_pediatric_dosages_ethambutol_in_children_(birth_to_15_years).html index 75dc41e..537fb0f 100644 --- a/app/src/main/assets/pages/table_11_pediatric_dosages_ethambutol_in_children_(birth_to_15_years).html +++ b/app/src/main/assets/pages/table_11_pediatric_dosages_ethambutol_in_children_(birth_to_15_years).html @@ -4,7 +4,7 @@ - + GA TB Reference Guide @@ -15,7 +15,9 @@
        -

        View in chapter -> Special Clinical Situations

        +

        View in chapter → Special Clinical Situations

        +

        Last Updated October 2025

        +
        @@ -77,6 +79,9 @@
        1600 mg
        +

        + The maximum recommendation for ethambutol is 1 g daily. +

        diff --git a/app/src/main/assets/pages/table_12_pediatric_dosages_pyrazinamide_in_children_(birth_to_15_years).html b/app/src/main/assets/pages/table_12_pediatric_dosages_pyrazinamide_in_children_(birth_to_15_years).html index 9a714df..4f80b62 100644 --- a/app/src/main/assets/pages/table_12_pediatric_dosages_pyrazinamide_in_children_(birth_to_15_years).html +++ b/app/src/main/assets/pages/table_12_pediatric_dosages_pyrazinamide_in_children_(birth_to_15_years).html @@ -4,7 +4,7 @@ - + GA TB Reference Guide @@ -15,7 +15,9 @@
        -

        View in chapter -> Special Clinical Situations

        +

        View in chapter → Special Clinical Situations

        +

        Last Updated October 2025

        +
        @@ -24,80 +26,80 @@ - + - + - + - + - + - + - + - + - + - + - + - + - +
        Child's Weight (lbs) Child's Weight (kg) Daily Dose (mg) 30-40 mg/kg POTwice-weekly Dose (mg) 50-70 mg/kg PO
        13 - 23 6 - 10.5 250 mg500 mg
        24 - 26 11 - 12 250 mg750 mg
        27 - 31 12.5 - 14 500 mg1000 mg
        32 - 41 14.5 - 18.5 500 mg1250 mg
        42 - 47 19.0 - 21.5 750 mg1250 mg
        48 - 54 22.0 - 24.5 750 mg1500 mg
        55 – 63 25 – 28.5 1000 mg1750 mg
        64 – 67 29 – 30.5 1000 mg2000 mg
        68 – 80 31 – 36.5 1250 mg2000 mg
        81 – 93 37 – 42.5 1500 mg2000 mg
        94 – 106 43 – 48.5 1750 mg2000 mg
        107 + 49 + 2000 mg2000 mg
        diff --git a/app/src/main/assets/pages/table_13_antituberculosis_antibiotics_in_adult_patients_with_renal_impairment.html b/app/src/main/assets/pages/table_13_antituberculosis_antibiotics_in_adult_patients_with_renal_impairment.html index eac6684..077e621 100644 --- a/app/src/main/assets/pages/table_13_antituberculosis_antibiotics_in_adult_patients_with_renal_impairment.html +++ b/app/src/main/assets/pages/table_13_antituberculosis_antibiotics_in_adult_patients_with_renal_impairment.html @@ -4,7 +4,7 @@ - + GA TB Reference Guide @@ -16,78 +16,239 @@
        -

        View in chapter -> Special Clinical Situations

        -

        NOTE: Drug adjustments are based on the creatinine clearance (CrCl) which can be estimated as follows:

        -

        [(140-age in yrs)(Ideal body weight in kg) for men (x 0l85 for women)] / [(72) (serum creatinine, mg/dL)]

        -

        Ideal body weight for men: 50 kg + 2.3 kg per inch over 5 feet

        -

        Ideal body weight for women: 45.5 kg + 2.3 kg per inch over 5 feet

        - - +

        View in chapter → Special Clinical Situations

        +

        Last Updated October 2025

        +
        - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
        DrugUsual Dose (UD) Normal Renal FunctionCrCl 30-90CrCL <30 or HemodialysisPeritoneal Dialysis
        INH300 mg/dayUDUDData currently are not available for patients receiving peritoneal dialysis. Until data - become available, begin with doses recommended for patients receiving hemodialysis and verify - adequacy of dosing using serum concentration monitoring. -
        Rifampin600 mg/dayUDUD
        Ethambutol15-25 mg/kg/dayUD20-25 mg/kg/dose thrice weekly
        Pyrazinamide25 mg/kg d (max 2 gm/day)UD25-35 mg/kg/dose thrice weekly
        Levofloxacin750 mg/dayUD750-1000 mg/dose thrice weekly
        Moxifloxacin400 mg/dayUDUD
        Amikacin15 mg/kg/daily or thrice weeklyUD15 mg/kg/dose thrice weekly
        Linezolid600 mg/dayUDUD
        +
        +
          +
          • +
          • +
          • +
          • +
          • +
          • +
          • +
          • +
        +
        + +

        + NOTE: Drug adjustments are based on the creatinine clearance (CrCl) which can be estimated as follows:
        + [(140-age in yrs)(Ideal body weight in kg) for men (x 0l85 for women)] / [(72) (serum creatinine, mg/dL)] + Ideal body weight for men: 50 kg + 2.3 kg per inch over 5 feet + Ideal body weight for women: 45.5 kg + 2.3 kg per inch over 5 feet +

        + +
        + + + + + + + + + + + + + + + + + + + +
        Usual Dose (UD) Normal Renal Function300 mg/day
        CrCl 30-90UD
        CrCl <30 or HemodialysisUD
        Peritoneal DialysisData currently are not available for patients receiving peritoneal dialysis. Until data + become available, begin with doses recommended for patients receiving hemodialysis and verify + adequacy of dosing using serum concentration monitoring. +
        +
        + +
        + + + + + + + + + + + + + + + + + + + +
        Usual Dose (UD) Normal Renal Function600 mg/day
        CrCl 30-90UD
        CrCl <30 or HemodialysisUD
        Peritoneal DialysisData currently are not available for patients receiving peritoneal dialysis. Until data + become available, begin with doses recommended for patients receiving hemodialysis and verify + adequacy of dosing using serum concentration monitoring. +
        +
        + +
        + + + + + + + + + + + + + + + + + + + +
        Usual Dose (UD) Normal Renal Function15-25 mg/kg/day
        CrCl 30-90UD
        CrCl <30 or Hemodialysis20-25 mg/kg/dose thrice weekly
        Peritoneal DialysisData currently are not available for patients receiving peritoneal dialysis. Until data + become available, begin with doses recommended for patients receiving hemodialysis and verify + adequacy of dosing using serum concentration monitoring. +
        +
        + +
        + + + + + + + + + + + + + + + + + + + +
        Usual Dose (UD) Normal Renal Function25 mg/kg d (max 2 gm/day)
        CrCl 30-90UD
        CrCl <30 or Hemodialysis25-35 mg/kg/dose thrice weekly
        Peritoneal DialysisData currently are not available for patients receiving peritoneal dialysis. Until data + become available, begin with doses recommended for patients receiving hemodialysis and verify + adequacy of dosing using serum concentration monitoring. +
        +
        + +
        + + + + + + + + + + + + + + + + + + + +
        Usual Dose (UD) Normal Renal Function750 mg/day
        CrCl 30-90UD
        CrCl <30 or Hemodialysis750-1000 mg/dose thrice weekly
        Peritoneal DialysisData currently are not available for patients receiving peritoneal dialysis. Until data + become available, begin with doses recommended for patients receiving hemodialysis and verify + adequacy of dosing using serum concentration monitoring. +
        +
        + +
        + + + + + + + + + + + + + + + + + + + +
        Usual Dose (UD) Normal Renal Function400 mg/day
        CrCl 30-90UD
        CrCl <30 or HemodialysisUD
        Peritoneal DialysisData currently are not available for patients receiving peritoneal dialysis. Until data + become available, begin with doses recommended for patients receiving hemodialysis and verify + adequacy of dosing using serum concentration monitoring. +
        +
        + +
        + + + + + + + + + + + + + + + + + + + +
        Usual Dose (UD) Normal Renal Function15 mg/kg/daily or thrice weekly
        CrCl 30-90UD
        CrCl <30 or Hemodialysis15 mg/kg/dose thrice weekly
        Peritoneal DialysisData currently are not available for patients receiving peritoneal dialysis. Until data + become available, begin with doses recommended for patients receiving hemodialysis and verify + adequacy of dosing using serum concentration monitoring. +
        +
        + +
        + + + + + + + + + + + + + + + + + + + +
        Usual Dose (UD) Normal Renal Function600 mg/day
        CrCl 30-90UD
        CrCl <30 or Hemodialysis600 mg/dose thrice weekly
        Peritoneal DialysisData currently are not available for patients receiving peritoneal dialysis. Until data + become available, begin with doses recommended for patients receiving hemodialysis and verify + adequacy of dosing using serum concentration monitoring. +
        +
        +
        • Standard doses are given unless there is intolerance.
        • The medications should be given after hemodialysis on the day of hemodialysis.
          • @@ -108,4 +269,5 @@ + diff --git a/app/src/main/assets/pages/table_14_antituberculosis_medications_which_may_be_used_for_patients_who_have_contraindications_to_or_intolerance.html b/app/src/main/assets/pages/table_14_antituberculosis_medications_which_may_be_used_for_patients_who_have_contraindications_to_or_intolerance.html index d880e37..bc3486a 100644 --- a/app/src/main/assets/pages/table_14_antituberculosis_medications_which_may_be_used_for_patients_who_have_contraindications_to_or_intolerance.html +++ b/app/src/main/assets/pages/table_14_antituberculosis_medications_which_may_be_used_for_patients_who_have_contraindications_to_or_intolerance.html @@ -4,7 +4,7 @@ - + GA TB Reference Guide @@ -16,44 +16,133 @@
          -

          View in chapter -> Special Clinical Situations

          +

          View in chapter → Special Clinical Situations

          +

          Last Updated October 2025

          +
          - - - - - - - - - - - - - - - - - - - - - - - - - - - -
          Medication: Route(s)Dosing (A for adults, C for children)Adverse Reactions
          Levofloxacin: PO/IVA: 750 mg daily C: 15 – 20 mg/kg daily Max dose 750 mgGI upset, dizziness, hypersensitivity, Headaches, QT prolongation, tendon rupture - (rare), arthralgia, increased risk for aortic dissection/rupture, hypo/hyperglycemia -
          Moxifloxacin: PO/IVA: 400 mg daily C: no established dose
          Linezolid: PO/IVA: 600 mg (once daily) C: 10 mg/kg/dose every 12 hours (max dose 600 mg)Myelosuppression, GI upset, optic and peripheral neuropathy (may be irreversible)
          Amikacin: IVA: 10 to 15 mg/kg/day 5-7 days per week or 3 times per week - C: 15 to 30 mg/kg/day (max dose 1 gram) 5-7 days per week or 3 times per week - Auditory, vestibular and renal toxicity
          + +
          +
            +
            • + +
          • + +
            • + +
            • + +
            • +
          +
          + +
          + + + + + + + + + + + +
          Dosing (A for adults, C for children) + A: 750 mg daily
          + C: 15 – 20 mg/kg daily
          + Max dose: 750 mg +
          Adverse Reactions + GI upset, dizziness, hypersensitivity, Headaches, QT prolongation, tendon rupture (rare), arthralgia, increased risk for aortic dissection/rupture, hypo/hyperglycemia +
          + +

          + Expert consultation is advised before use; agent is not approved for children less than 18 years of age. +

          +
          + +
          + + + + + + + + + + + +
          Dosing (A for adults, C for children) + A: 10-15 mg/kg
          + C: No established dose
          + Max dose: 400 mg +
          Adverse Reactions + GI upset, dizziness, hypersensitivity, Headaches, QT prolongation, tendon rupture (rare), arthralgia, increased risk for aortic dissection/rupture, hypo/hyperglycemia +
          + +

          + Expert consultation is advised before use; agent is not approved for children less than 18 years of age. +

          +
          + +
          + + + + + + + + + + + +
          Dosing (A for adults, C for children) + A: 600 mg (once daily)
          + C: + Children < 12 years: +
            +
          • 5 – 10 kg: 15 mg/kg once daily
            • +
          • 10 – 23 kg: 12 mg/kg once daily
            • +
          • >23 kg: 10 mg/kg once daily
            • +
          + Children ≥12 years: +
            +
          • 10 mg/kg once daily
            • +
          + Max dose: 600 mg +
          Adverse Reactions + Myelosuppression, GI upset, optic and peripheral neuropathy (may be irreversible) +
          +
          + +
          + + + + + + + + + + + +
          Dosing (A for adults, C for children) + A: 10 to 15 mg/kg/day
          + 5-7 days per week or 3 times per week

          + + C: 15 to 30 mg/kg/day (max dose 1 gram)
          + 5-7 days per week or 3 times per week +
          Adverse Reactions + Auditory, vestibular and renal toxicity +
          +
          + diff --git a/app/src/main/assets/pages/table_15_clinical_situations_for_which_standard_therapy_cannot_be_given_or_is_not_well_tolerated.html b/app/src/main/assets/pages/table_15_clinical_situations_for_which_standard_therapy_cannot_be_given_or_is_not_well_tolerated.html index 025ae38..b594e97 100644 --- a/app/src/main/assets/pages/table_15_clinical_situations_for_which_standard_therapy_cannot_be_given_or_is_not_well_tolerated.html +++ b/app/src/main/assets/pages/table_15_clinical_situations_for_which_standard_therapy_cannot_be_given_or_is_not_well_tolerated.html @@ -4,116 +4,194 @@ - + GA TB Reference Guide -
          -

          View in chapter -> Special Clinical Situations

          -
          - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - +

          View in chapter → Special Clinical Situations

          +

          Last Updated October 2025

          +
          +
          +
          +
          + + + + + + + +
          + +
          +
          Clinical SituationConcerns RaisedRegimenComments
          Critical illness requiring vasopressorsPoor gut medication absorptionIV rifampin ≥ 10 mg/kg daily - PO pyrazinamide UD - PO ethambutol UD - IV isoniazid UD2,3 - IV levofloxacin or moxifloxacin UD 4 - IV linezolid UD 54 - IV amikacin UD5Oral medications are generally poorly bioavailable among critically ill patients.

          Patients - receiving sedation are unable to report isoniazid or linezolid-induced neuropathies nor - aminoglycoside- induced otovestibular toxicity

          Proven or suspected meningeal TBRapidly progressive and often fatal. High plasma levels needed to achieve adequate CNS penetration. - High index of suspicion necessary; microbiological diagnostic tests have low yield. - IV rifampin ≥ 10 mg/kg daily - PO or IV2 2 isoniazid UD - PO pyrazinamide UD - PO ethambutol UD (adults) - PO ethionamide (children) -

          Consider adding IV levofloxacin or moxifloxacin UD in lieu of ethambutol

          		Rifampin has poor CNS penetration but is an essential drug for meningeal TB treatment. Isoniazid, - pyrazinamide, levofloxacin, and moxifloxacin have excellent CNS penetration. -

          Ethambutol has poor CNS penetration. Early use of fluoroquinolones has been associated with - improved outcomes among patients with isoniazid-resistant meningeal TB

          -
          Patient age 75 years or greater6Increased risk for pyrazinamide-induced hepatotoxicityCan consider rifampin, isoniazid, and ethambutol without pyrazinamide when drug-susceptibility is - known and/or patient has low burden of disease - 3-drug regimens may increase risk of failure or acquired drug-resistance.
          Disseminated TB with concern for poor absorption from gut6Disseminated TB is associated with gut edema which decreases po medication bioavailabilityStandard 4-drug regimen Consider increasing po Rifampin dose (15 to 20 mg/kg daily, minimum 600 mg) - Consider IV rifampin and IV isoniazid 1 for inpatients. - Consider obtaining TB drug levels in ensure po dosing achieves at least minimum levels
          Patient receiving medications via nasogastric or PEG tube6Tube feeds may decrease TB drug bioavailabilityNo change in standard TB regimenHold tube feeds ≤2 hours prior and ≥1 hour after TB drug intake. Longer intervals are needed if - quinolone- containing regimens are given with divalent-cationcontainingtubefeeds -
          Baseline elevation of liver enzymes6Consider limiting number of hepatotoxic drugs for patients with baseline ALT>3x UNL and/or advanced - liver disease. - Order of hepatotoxicity: PZA>INH>RIF - 1-RIF/INH/EMB +/- FQN 2-RIF/EMB/FQN +/- LZD or AG 3-EMB/FQN +/- LZD or AGConsider baseline liver enzyme elevation could be due to hepatic TB -

          3-drug regimens may increase risk of failure or acquired drug-resistance.

          -
          Acute hepatitis after starting standard therapy6TB drug-induced hepatotoxicity - Stop TB drugs if ALT>3x UNL and patient symptomatic or ALT >5x UNL regardless of symptoms - Sequential re-introduction of TB drugs once ALT <2x UNL. - (1) Rifamycin x 5-7 days - (2) Isoniazid x 5-7 days - (3) Ethambutol x 5-7 days - (4) Need and choice of 4th agent depends on burden of disease and drug-susceptibility pattern. - Pyrazinamide is often the culprit and effective regimens can be designed without this drug. - Rifamycins are the drugs most important for sterilizing activity (i.e., cure) in TB treatment. - Consider adding a 4th drug if patient has high burden of disease. -
          + + + + + + + + + + + + + + +
          Concerns RaisedPoor gut medication absorption
          Regimen1-IV rifampin ≥ 10 mg/kg daily+
          + 2-PO pyrazinamide UD+
          + 3-PO ethambutol UD+
          + 4-IV isoniazid UD2,3+
          + 5-IV levofloxacin or moxifloxacin UD 4+
          + 6-IV linezolid UD 54+
          + 7-IV amikacin UD5
          CommentsOral medications are generally poorly bioavailable among critically ill patients.

          Patients + receiving sedation are unable to report isoniazid or linezolid-induced neuropathies nor + aminoglycoside- induced otovestibular toxicity

          +
          + +
          + + + + + + + + + + + + + + + +
          Concerns RaisedRapidly progressive and often fatal. High plasma levels needed to achieve adequate CNS penetration. + High index of suspicion necessary; microbiological diagnostic tests have low yield.
          Regimen1-IV rifampin ≥ 10 mg/kg daily+
          + 2-PO or IV2 2 isoniazid UD+
          + 3-PO pyrazinamide UD+
          + 4-PO ethambutol UD (adults) or + PO ethionamide (children) +

          Consider adding IV levofloxacin or moxifloxacin UD in lieu of ethambutol, especially if there is concern for isoniazid-resistant TB.

          CommentsRifampin has poor CNS penetration but is an essential drug for meningeal TB treatment. Isoniazid, + pyrazinamide, levofloxacin, and moxifloxacin have excellent CNS penetration. +

          Ethambutol has poor CNS penetration. Early use of fluoroquinolones has been associated with + improved outcomes among patients with isoniazid-resistant meningeal TB

          +
          + +
          + + + + + + + + + + + + + + + +
          Concerns RaisedIncreased risk for pyrazinamide-induced hepatotoxicity
          RegimenCan consider rifampin, isoniazid, and ethambutol without pyrazinamide when drug-susceptibility is + known and/or patient has low burden of disease
          Comments3-drug regimens may increase risk of failure or acquired drug-resistance.
          +
          + +
          + + + + + + + + + + + + + + + +
          Concerns RaisedDisseminated TB is associated with gut edema which decreases po medication bioavailability
          RegimenStandard 4-drug regimen Consider increasing po Rifampin dose (15 to 20 mg/kg daily, minimum 600 mg) + Consider IV rifampin and IV isoniazid 1 for inpatients.
          CommentsConsider obtaining TB drug levels in ensure po dosing achieves at least minimum levels
          +
          + +
          + + + + + + + + + + + + + + + +
          Concerns RaisedTube feeds may decrease TB drug bioavailability
          RegimenNo change in standard TB regimen
          CommentsHold tube feeds ≤2 hours prior and ≥1 hour after TB drug intake. Longer intervals are needed if + quinolone- containing regimens are given with divalent-cationcontainingtubefeeds
          +
          + +
          + + + + + + + + + + + + + + + +
          Concerns RaisedConsider limiting number of hepatotoxic drugs for patients with baseline ALT>3x UNL and/or advanced + liver disease. + Order of hepatotoxicity: PZA>INH>RIF
          Regimen1-RIF/INH/EMB +/- FQN 2-RIF/EMB/FQN +/- LZD or AG 3-EMB/FQN +/- LZD or AG
          CommentsConsider baseline liver enzyme elevation could be due to hepatic TB +

          3-drug regimens may increase risk of failure or acquired drug-resistance.

          +
          + +
          + + + + + + + + + + + + + + + +
          Concerns RaisedTB drug-induced hepatotoxicity + Stop TB drugs if ALT>3x UNL and patient symptomatic or ALT >5x UNL regardless of symptoms
          RegimenSequential re-introduction of TB drugs once ALT <2x UNL. + (1) Rifamycin x 5-7 days + (2) Isoniazid x 5-7 days + (3) Ethambutol x 5-7 days + (4) Need and choice of 4th agent depends on burden of disease and drug-susceptibility pattern.
          CommentsPyrazinamide is often the culprit and effective regimens can be designed without this drug. + Rifamycins are the drugs most important for sterilizing activity (i.e., cure) in TB treatment. + Consider adding a 4th drug if patient has high burden of disease.
          +
          - -

          Abbreviations: UD, usual dose; UNL, upper normal limit.

          TABLE 15 NOTES

          1-Some of these recommendations differ or are not addressed by 2016 ATS/CDC/IDSA drug-susceptible TB @@ -125,9 +203,18 @@

          5-Associated with otovestibular toxicity

          6-These recommendations are meant for patients with known drug-susceptible TB or at low risk for drug- resistant TB

          +
        + + diff --git a/app/src/main/assets/pages/table_16_when_to_start_hiv_therapy.html b/app/src/main/assets/pages/table_16_when_to_start_hiv_therapy.html index 1cc5130..d24775b 100644 --- a/app/src/main/assets/pages/table_16_when_to_start_hiv_therapy.html +++ b/app/src/main/assets/pages/table_16_when_to_start_hiv_therapy.html @@ -4,7 +4,7 @@ - + GA TB Reference Guide @@ -16,7 +16,9 @@
        -

        View in chapter -> Antiretroviral Therapy (ART) and Treatment of Persons Living with HIV and Active TB

        +

        View in chapter → Antiretroviral Therapy (ART) and Treatment of Persons Living with HIV and Active TB

        +

        Last Updated October 2025

        +
        @@ -30,26 +32,25 @@ - + - - + +
        ART Initiation
        < 50 cells/mm3**< 50 cells/mm³ within 2 weeks of starting TB therapy.
        > 50 cells/mm3**by 8 to 12 weeks of starting TB therapy> 50 cells/mm³within 2-8 weeks of starting TB therapy
        Pregnant, any CD4 count As early as feasible
        -

        ** EXCEPTION: tuberculous meningitis. To avoid life-threatening CNS immune reconstitution inflammatory - syndrome (IRIS), persons living with HIV and tuberculous meningitis should not be started on ART until AFTER - 8 weeks of TB therapy

        -

        Above based on guidelines developed by the Department of Health and Human Services (DHHS) Panel on Guidelines - for Use of Antiretroviral Agents for Adults and Adolescents and Use of Antiretroviral Drugs in Pregnant - Women with HIV Infection and Interventions to Reduce Perinatal Transmission in the United States, last - reviewed and updated April 15, 2019 (https://aidsinfo.nih.gov/guidelines). -

        +

        ** EXCEPTION: tuberculous meningitis. To avoid life-threatening CNS immune reconstitution inflammatory syndrome (IRIS), persons living with HIV and tuberculous meningitis should not be started on ART until AFTER the TB meningitis is under control and at least two weeks anti-TB treatment

        +

        + PREVENTING IRIS (Immune Reconstitution Inflammatory Syndrome): prednisone 40 mg/day for 2 weeks followed by 20 mg/day for 2 weeks is recommended for people with CD4 100 cells/mm3 who start ART within 30 days of TB treatment, are responding well to treatment, do not have known or suspected rifampin resistance, Kaposi sarcoma, or active hepatitis B. This recommendation does not apply to people with CNS TB for whom steroids are recommended from the time TB treatment is started. +

        +

        + Above based on guidelines developed by the Department of Health and Human Services (DHHS) Panel on Guidelines for Use of Antiretroviral Agents for Adults and Adolescents and Use of Antiretroviral Drugs in Pregnant Women living with HIV and Interventions to Reduce Perinatal Transmission in the United States, last reviewed and updated October 29, 2024 (https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-opportunistic-infections/mycobacterium?view=full) +

        diff --git a/app/src/main/assets/pages/table_17_what_to_start_choice_of_tb_therapy_and_antiretroviral_therapy_(art)_when)treating_co-infected_patients.html b/app/src/main/assets/pages/table_17_what_to_start_choice_of_tb_therapy_and_antiretroviral_therapy_(art)_when)treating_co-infected_patients.html index c17f535..8ec97f7 100644 --- a/app/src/main/assets/pages/table_17_what_to_start_choice_of_tb_therapy_and_antiretroviral_therapy_(art)_when)treating_co-infected_patients.html +++ b/app/src/main/assets/pages/table_17_what_to_start_choice_of_tb_therapy_and_antiretroviral_therapy_(art)_when)treating_co-infected_patients.html @@ -16,7 +16,7 @@
        -

        View in chapter -> Antiretroviral Therapy (ART) and Treatment of Persons Living with HIV and Active TB

        +

        View in chapter → Antiretroviral Therapy (ART) and Treatment of Persons Living with HIV and Active TB

        diff --git a/app/src/main/assets/pages/table_17_what_to_start_choice_of_tb_therapy_and_antiretroviral_therapy_(art)_when_treating_co-infected_patients.html b/app/src/main/assets/pages/table_17_what_to_start_choice_of_tb_therapy_and_antiretroviral_therapy_(art)_when_treating_co-infected_patients.html new file mode 100644 index 0000000..6473725 --- /dev/null +++ b/app/src/main/assets/pages/table_17_what_to_start_choice_of_tb_therapy_and_antiretroviral_therapy_(art)_when_treating_co-infected_patients.html @@ -0,0 +1,123 @@ + + + + + + + + GA TB Reference Guide + + + + + + + + + +
        +

        View in chapter → Antiretroviral Therapy (ART) and Treatment of Persons Living with HIV and Active TB

        +

        Last Updated June 2024

        +
        +
        +
        + + + + + + + + + + + + + + + + + + + + +
        Principle: Despite Drug Interactions, a Rifamycin (Rifampin or Rifabutin) Should Be Included in TB Regimens for Patients + Receiving ART, with Dosage Adjustment if Necessary (see Table SMR11 for dosage + adjustments). +
        Option 1: Rifabutin-based + ART regimen: Integrase inhibitor and 2 NRTIs + Preferred ART choices: RAL or DTG + TDF/FTC + Alternative ART choices: DTG + ABC/3TC + Contraindicated medications: TAF, other integrase inhibitors (Bictegravir, Elvitegravir) + NOTE: Dolutegravir has higher barrier to resistance compared to raltegravir. Dolutegravir is + preferred when there is high risk poor adherence. +
        Option 2: Rifampin-based + ART regimen: Efavirenz and 2 NRTIs + Preferred ART choices: Efavirenz (NNRTI) + (TDF/FTC) Alternative ART choices: Efavirenz + ABC/3TC + Contraindicated medications: TAF, other NNRTIs: Nevaripine, Doravirine, Etravirine, or Rilpivirine + NOTE: Efavirenz is not a preferred regimen for patients initiating ART. Integrase inhibitors DTG and + RAL are preferred ART regimens for patients initiating ART but require BID dosing if used with + rifampin. Efavirenz has low barrier to resistance making this regimen less suitable when there is + high risk for poor adherence. Efavirenz is associated with neuropsychiatric side-effects. Screening + for depression and suicidality is recommended prior to and during efavirenz-based regimens. + Efavirenz + ABC/3TC is associated with higher rates of virologic failure when baseline HIV viral + load is >100.000 copies/ml. +
        Option 3: Rifabutin-based (dose adjusted) + ART regimen: boosted PI and 2 NRTIs + Preferred ART choices: ATV/r or ATV/c + TDF/FTC + DRV/r or DRV/c + TDF/FTC Alternative ART choices: ABC/3TC in place of TDF/FTC + Contraindicated medications: TAF + NOTE: PI’s have high barrier to resistance. However, given rifabutin is given at half-dose when used + with PI’s adherence to ART should be closely monitored. Poor adherence to PI’s while on rifabutin + increases risk for rifampin resistance. +
        Option 4: Rifampin-based + ART regimen: dose adjusted integrase inhibitor + 2 NRTIs + Preferred ART choices: RAL (dose adjusted) or DTG (dose adjusted)+ TDF/FTC Alternative ART choices: + DTG (dose adjusted) + ABC/3TC + Contraindicated medications: TAF, other integrase inhibitors (Bictegravir, Elvitegravir) + NOTE: Dolutegravir has higher barrier to resistance compared to raltegravir. Dolutegravir is + preferred when there is high risk poor adherence. +
        Choice for Pregnant women with active TB and HIV infection: + TB regimen: Rifabutin –based (dose adjusted) + ART regimen: boosted PI (ARV/r or DRV/r) 2 + 2 NRTIs (TDF/FTC or ABC/3TC) + NOTE: Preliminary data suggest that there is an increased risk of neural tube defects in infants + born to women who were receiving DTG at the time of conception. DTG is contraindicated for pregnant + women during first trimester and for women who are planning to become pregnant or are not using + effective contraception. DTG is the preferred integrase inhibitor after first trimester 1. +
        + +
          +
        • NRTIs: nucleoside/-tide reverse transcriptase inhibitors
          • +
        • NNRTIs: non-nucleoside reverse transcriptase inhibitors
          • +
        • PIs: protease inhibitors
          • +
        • /r: boosted with ritonavir
          • +
        • /c: boosted with cobicistat
          • +
        • TDF: Tenofovir disoproxil fumarate
          • +
        • TAF: Tenofovir alafenamide
          • +
        • FTC: Emtricitabine
          • +
        • 3TC: Lamivudine
          • +
        • ABC: Abacavir
          • +
        • ATV/r: Atazanavir/ritonavir
          • +
        • DRV/r: Daraunavir/ritonavir
          • +
        • RAL: Raltegravir
          • +
        • DTG: Dolutegravir
          • +
        + +

        Above based on guidelines developed by the Department of Health and Human Services (DHHS) Panel on Guidelines + for Use of Antiretroviral Agents for Adults and Adolescents and Use of Antiretroviral Drugs in Pregnant + Women with HIV Infection and Interventions to Reduce Perinatal Transmission in the United States, last + reviewed and updated April 15, 2019 (http://aidsinfo.nih.gov/guidelines). +

        + +

        1-Data on integrase inhibitors and pregnancy outcomes is rapidly evolving and DHHS guidelines are frequently + updated.

        + +

        2-Cobicistat is currently not recommended for pregnant women.

        + +
        +
        + + + + diff --git a/app/src/main/assets/pages/table_18_dosage_adjustments_for_art_and_rifamycins_when_used_in_combination.html b/app/src/main/assets/pages/table_18_dosage_adjustments_for_art_and_rifamycins_when_used_in_combination.html index 6b0d379..df41e84 100644 --- a/app/src/main/assets/pages/table_18_dosage_adjustments_for_art_and_rifamycins_when_used_in_combination.html +++ b/app/src/main/assets/pages/table_18_dosage_adjustments_for_art_and_rifamycins_when_used_in_combination.html @@ -4,50 +4,141 @@ - + GA TB Reference Guide -

        Table 18. Dosage Adjustments for ART and Rifamycins when used in Combination

        - - -

        *Preliminary data suggest that there is an increased risk of neural tube defects in infants born to women - who were receiving DTG at the time of conception. DTG is contraindicated for pregnant women during first - trimester and for women who are planning to become pregnant or are not using effective contraception. - DTG is the preferred integrase inhibitor after first trimester.

        - -
          -
        • NNRTIs: non-nucleoside reverse transcriptase inhibitors
          • -
        • PIs: protease inhibitors
          • -
        • ATV/r: Atazanavir/ritonavir
          • -
        • DRV/r: Daraunavir/ritonavir
          • -
        • LPV/r: Lopinavir/ritonavir
          • -
        • RAL: Raltegravir
          • -
        • DTG: Dolutegravir
          • -
        • /c : boosted with cobicistat
          • -
        - -

        Table 18 is based on guidelines developed by the Department of Health and Human Services (DHHS) Panel on - Guidelines for Use of Antiretroviral Agents for Adults and Adolescents and Use of Antiretroviral Drugs - in Pregnant Women with HIV Infection and Interventions to Reduce Perinatal Transmission in the United - States, last reviewed and updated April 15, 2019 - (aidsinfo.nih.gov/guidelines)

        - -

        1-Data on integrase inhibitors and pregnancy outcomes is rapidly evolving and DHHS - guidelines are frequently updated.

        - -

        2-Cobicistat is currently not recommended for pregnant women.

        +

        Last Updated October 2025

        +
        +
        +
        +
        + + + +
        + +
        +

        Dolutegravir (DTG)

        + + + + + + + + + + + + + + + + +
        DrugDosing
        Rifampin (RIF)RIF: No change (600 mg)
        DTG: Increase to 50 mg BID
        Rifabutin (RBT)RBT: No change (300 mg)
        DTG: No change (50 mg)
        +
        + +
        +

        ATV/r, DRV/r

        + + + + + + + + + + + + + + + +
        DrugDosing
        Rifampin (RIF)DO NOT USE
        Rifabutin (RBT)RBT: decrease to 150 mg/d
        PIs: no change
        +
        + +
        +

        Efavirenz (EFV)
        (Note: No longer a first line ART)

        + + + + + + + + + + + + + + + +
        DrugDosing
        Rifampin (RIF)RIF no change (600 mg)
        EFV: no change (600 mg qhs)
        Rifabutin (RBT)DO NOT USE
        +
        +

        + Department of Human Health Services links for ART drug-drug interactions – these are updated frequently

        +

        Protease inhibitors: https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-arv/drug-interactions-protease-inhibitors?view=full

        + +

        NNRTIs: https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-arv/drug-interactions-nnrti?view=full

        + +

        NRTIs: https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-arv/drug-interactions-nrti?view=full

        + +

        Integrase inhibitors: https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-arv/drug-interactions-insti?view=full

        + +

        *Preliminary data suggest that there is an increased risk of neural tube defects in infants born to women + who were receiving DTG at the time of conception. DTG is contraindicated for pregnant women during first + trimester and for women who are planning to become pregnant or are not using effective contraception. + DTG is the preferred integrase inhibitor after first trimester.

        + +
          +
        • NNRTIs: non-nucleoside reverse transcriptase inhibitors
          • +
        • PIs: protease inhibitors
          • +
        • ATV/r: Atazanavir/ritonavir
          • +
        • DRV/r: Daraunavir/ritonavir
          • +
        • LPV/r: Lopinavir/ritonavir
          • +
        • RAL: Raltegravir
          • +
        • DTG: Dolutegravir
          • +
        • /c : boosted with cobicistat
          • +
        + +

        Table 18 is based on guidelines developed by the Department of Health and Human Services (DHHS) Panel on + Guidelines for Use of Antiretroviral Agents for Adults and Adolescents and Use of Antiretroviral Drugs + in Pregnant Women with HIV Infection and Interventions to Reduce Perinatal Transmission in the United + States, last reviewed and updated April 15, 2019 + (aidsinfo.nih.gov/guidelines)

        + +

        1-Data on integrase inhibitors and pregnancy outcomes is rapidly evolving and DHHS + guidelines are frequently updated.

        + +

        2-Cobicistat is currently not recommended for pregnant women.

        +
        +
        + + diff --git a/app/src/main/assets/pages/table_19_guidelines_for_treatment_of_extrapulmonary_tuberculosis.html b/app/src/main/assets/pages/table_19_guidelines_for_treatment_of_extrapulmonary_tuberculosis.html index 80b51e0..25c9536 100644 --- a/app/src/main/assets/pages/table_19_guidelines_for_treatment_of_extrapulmonary_tuberculosis.html +++ b/app/src/main/assets/pages/table_19_guidelines_for_treatment_of_extrapulmonary_tuberculosis.html @@ -4,116 +4,252 @@ - + GA TB Reference Guide -
        -

        View in chapter -> Adjunctive Use of Corticosteroid Therapy

        -
        - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
        SiteLength of therapy with standard regimen and normal host (months)CorticosteroidsSteroid dosing A (adults) C (children)Additional management considerations
        Lymph node6Not recommendedPursue microbiologic proof of diagnosis prior to starting Rx
        Bone (non-vertebral) and joint6 to 9Not recommendedExtend to 12 months if hardware is present
        Spine without meningitis6 to 9Not recommended for TB rx but may be indicated for cord compressionMost spine infection can be cured with medical Rx. Surgery indicated for relief of cord - compression, progressive disease despite medical therapy, instability of the spine. -
        Spine with meningitis9 to 12Strongly recommendedA and C >= 25kg: 12 mg/day of dexamethasone x 3 weeks followed by 3- week taper

        C < - 25kg:8 mg /day of dexamethasone for 3 weeks followed by 3- week taper

        CNS tuberculosis including meningitis6 to 9Strongly recommendedNegative CSF culture or PCR test does NOT exclude this diagnosis

        Follow CSF profile for response - to therapy

        Pleural disease6Not recommendedEmpyema may require decortication
        Pericarditis6NO LONGER routinely RECOMMENDEDConsider steroids for patients at highest risk of later constriction: - large pericardial effusions high levels of inflammatory cells or markers in pericardial fluid those - with early signs of constriction -
        Disseminated disease6Not recommendedObtain cultures from blood, urine and sputum in addition to clinically apparent sites of disease. -
        Genitourinary6Not recommended
        Peritoneal6Not recommended
        -

        *ALWAYS EVALUATE for concomitant pulmonary involvement with respiratory samples for smear and culture - (regardless of chest imaging findings).

        +

        View in chapter → Adjunctive Use of Corticosteroid Therapy

        +

        Last Updated October 2025

        +
        +
        +
        +
        + + + + + + + + + + +
        + +
        + + + + + + + + + + + + + + + +
        Length of therapy6 months
        CorticosteroidsNot recommended
        Additional management considerationsPursue microbiologic proof of diagnosis prior to starting Rx
        +
        + +
        + + + + + + + + + + + + + + + +
        Length of therapy6 to 9 months
        CorticosteroidsNot recommended
        Additional management considerationsExtend to 12 months if hardware is present
        +
        + +
        + + + + + + + + + + + + + + + +
        Length of therapy6 to 9 months
        CorticosteroidsNot recommended for TB rx but may be indicated for cord compression
        Additional management considerationsMost spine infection can be cured with medical Rx. Surgery indicated for relief of cord + compression, progressive disease despite medical therapy, instability of the spine.
        +
        + +
        + + + + + + + + + + + + + + + + + + + +
        Length of therapy9 to 12 months
        CorticosteroidsStrongly recommended
        Steroid dosingA and C ≥ 25kg: 12 mg/day of dexamethasone x 3 weeks followed by 3-week taper +

        C < 25kg: 8 mg/day of dexamethasone for 3 weeks followed by 3-week taper

        Additional management considerationsMost spine infection can be cured with medical Rx. Surgery indicated for relief of cord + compression, progressive disease despite medical therapy, instability of the spine.
        +
        + +
        + + + + + + + + + + + + + + + +
        Length of therapy9-12 months
        CorticosteroidsStrongly recommended
        Additional management considerationsNegative CSF culture or PCR test does NOT exclude this diagnosis +

        Follow CSF profile for response to therapy

        +
        + +
        + + + + + + + + + + + + + + + +
        Length of therapy6 months
        CorticosteroidsNot recommended
        Additional management considerationsEmpyema may require decortication
        +
        + +
        + + + + + + + + + + + + + + + +
        Length of therapy6 months
        CorticosteroidsNO LONGER routinely RECOMMENDED
        Additional management considerationsConsider steroids for patients at highest risk of later constriction: + large pericardial effusions high levels of inflammatory cells or markers in pericardial fluid those + with early signs of constriction
        +
        + +
        + + + + + + + + + + + + + + + +
        Length of therapy6 months
        CorticosteroidsNot recommended
        Additional management considerationsObtain cultures from blood, urine and sputum in addition to clinically apparent sites of disease.
        +
        + +
        + + + + + + + + + + + + + + + +
        Length of therapy6 months
        CorticosteroidsNot recommended
        Additional management considerations
        +
        + +
        + + + + + + + + + + + + + + + +
        Length of therapy6 months
        CorticosteroidsNot recommended
        Additional management considerations
        +
        -

        Based on CID 2016:63 (1 October) • Nahid et al

        +

        + 2 mg/kg prednisone daily over three weeks, followed by taper Maximum dose 60 mg
        OR
        + Dexamethasone 0.3-0.6 mg/kg daily over three weeks, followed by taper Round to nearest tablet size (2, 4, 6 mg) Maximum dose 12 mg +

        +
        + + diff --git a/app/src/main/assets/pages/table_1_interpretation_criteria_for_the_quantiferon_tb_gold_plus_test.html b/app/src/main/assets/pages/table_1_interpretation_criteria_for_the_quantiferon_tb_gold_plus_test.html index e2308dc..37872ab 100644 --- a/app/src/main/assets/pages/table_1_interpretation_criteria_for_the_quantiferon_tb_gold_plus_test.html +++ b/app/src/main/assets/pages/table_1_interpretation_criteria_for_the_quantiferon_tb_gold_plus_test.html @@ -4,7 +4,7 @@ - + GA TB Reference Guide @@ -15,60 +15,110 @@
        -

        View in chapter -> Interferon-y Release Assays (IGRAs)

        -
        - +

        View in chapter → Interferon-y Release Assays (IGRAs)

        +

        Last Updated October 2025

        +
        +
        +
        +
          +
          • +
          • +
          • +
        +
        + +
        + + + + + + + + + + + + + + + + + + + + + + + + +
        Nil (IU/ml) < 8.0
        TB1 minus Nil (IU/ml)> 0.35 and > 25% of NilAny
        TB2 minus Nil (IU/ml)Any> 0.35 and > 25% of Nil
        Mitogen minus NilAny
        Report/InterpretationM. tuberculosis infection likely
        + + + + + + + + + + + + + + + + + + + + + + + + + +
        Nil (IU/ml) < 8.0
        TB1 minus Nil (IU/ml)< 0.35 or > 0.35 and < 25 % of Nil
        TB2 minus Nil (IU/ml)< 0.35 or > 0.35 and < 25% of Nil
        Mitogen minus Nil > 0.50
        Report/InterpretationM. tuberculosis infection not likely
        + + - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - + + + + + + + + + + + + + + + + + + + + + + + +
        Nil (IU/ml)TB1 minus Nil (IU/ml)TB2 minus Nil (IU/ml)Mitogen minus NilQFT-Plus ResultReport/Interpretation
        < 8.0> 0.35 and > 25% of NilAnyAnyPositiveM. tuberculosis infection likely
        Any> 0.35 and > 25% of Nil
        < 0.35 or > 0.35 and < 25% of Nil< 0.35 or > 0.35 and < 25% of Nil> 0.50 NegativeM. tuberculosis infection NOT likely
        < 0.35 or > 0.35 and < 25 % of Nil< 0.35 or > 0.35 and < 25% of Nil< 0.50IndeterminateLikelihood of M. tuberculosis infection cannot be determined
        > 8.0Any
        Nil (IU/ml) < 8.0> 8.0
        TB1 minus Nil (IU/ml)< 0.35 or > 0.35 and < 25% of NilAny
        TB2 minus Nil (IU/ml)< 0.35 or > 0.35 and < 25% of NilAny
        Mitogen minus Nil < 0.50Any
        Report/InterpretationLikelihood of M. tuberculosis infection cannot be determined

        Source: Based on manufacturer recommendations for QuantiFERON-TB Gold Plus [Package insert].
        Available at: - - https://www.quantiferon.com/us/wp-content/uploads/sites/13/2020/01/L1095849-R06-QFT-Plus-ELISA-IFU.pdf + + https://www.qiagen.com/us/resources/resource?id=ac068fc7-a994-4443-ac7c-dda43ce2bc5e&lang=en

        + diff --git a/app/src/main/assets/pages/table_20_use_of_anti-tb_medications_in_special_situations_pregnancy_tuberculosis_meningitis_and_renal_failure.html b/app/src/main/assets/pages/table_20_use_of_anti-tb_medications_in_special_situations_pregnancy_tuberculosis_meningitis_and_renal_failure.html index edfe84c..4c7946f 100644 --- a/app/src/main/assets/pages/table_20_use_of_anti-tb_medications_in_special_situations_pregnancy_tuberculosis_meningitis_and_renal_failure.html +++ b/app/src/main/assets/pages/table_20_use_of_anti-tb_medications_in_special_situations_pregnancy_tuberculosis_meningitis_and_renal_failure.html @@ -4,98 +4,243 @@ - + GA TB Reference Guide -
        -

        View in chapter -> Treatment of Active TB in Pregnancy

        -
        - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
        DrugSafety in Pregnancy (1)Central Nervous System Penetration (2)Dosage in Renal Insufficiency (3)
        IsoniazidSafe (4)Good (20-100%)No change
        RifampinSafe (isolated reports of malformation)Fair, Inflamed meninges (10- 20%)No change
        PyrazinamideCaution (1)Good (75-100%)Decrease dose/ Increase interval
        EthambutolSafeInflamed meninges only (4-64%)Decrease dose/ Increase interval
        Aminoglycosides (Streptomycin, Kanamycin, Amikacin)AvoidPoor (5)Decrease dose/ Increase interval (6)
        CapreomycinAvoidPoorDecrease dose/ Increase interval (6)
        Levofloxacin, Moxifloxacin GatifloxacinDo not useFair (5-10%) Inflamed meninges (50-90%)Decrease dose/ Increase interval (7)
        EthionamideAvoidGood (100%)No change
        CycloserineAvoidGood (50-100%)Decrease dose/ Increase interval
        Para-amino-silicylic acidSafeInflamed meninges - only (50-100%) - Incomplete data
        ClofazimineAvoidUnknownProbably no change
        +

        View in chapter → Treatment of Active TB in Pregnancy

        +

        Last Updated October 2025

        +
        +
        +
        +
        + + + + + + + + + + + +
        + +
        + + + + + + + + + + + + + + + +
        Safety in PregnancySafe (4)
        Central Nervous System PenetrationGood (20-100%)
        Dosage in Renal InsufficiencyNo change
        +
        + +
        + + + + + + + + + + + + + + + +
        Safety in PregnancySafe (isolated reports of malformation)
        Central Nervous System PenetrationFair, Inflamed meninges (10-20%)
        Dosage in Renal InsufficiencyNo change
        +
        + +
        + + + + + + + + + + + + + + + +
        Safety in PregnancyCaution (1)
        Central Nervous System PenetrationGood (75-100%)
        Dosage in Renal InsufficiencyDecrease dose/ Increase interval
        +
        + +
        + + + + + + + + + + + + + + + +
        Safety in PregnancySafe
        Central Nervous System PenetrationInflamed meninges only (4-64%)
        Dosage in Renal InsufficiencyDecrease dose/ Increase interval
        +
        + +
        + + + + + + + + + + + + + + + +
        Safety in PregnancyAvoid
        Central Nervous System PenetrationPoor (5)
        Dosage in Renal InsufficiencyDecrease dose/ Increase interval (6)
        +
        + +
        + + + + + + + + + + + + + + + +
        Safety in PregnancyAvoid
        Central Nervous System PenetrationPoor
        Dosage in Renal InsufficiencyDecrease dose/ Increase interval (6)
        +
        + +
        + + + + + + + + + + + + + + + +
        Safety in PregnancyDo not use
        Central Nervous System PenetrationFair (5-10%) Inflamed meninges (50-90%)
        Dosage in Renal InsufficiencyDecrease dose/ Increase interval (7)
        +
        + +
        + + + + + + + + + + + + + + + +
        Safety in PregnancyAvoid
        Central Nervous System PenetrationGood (100%)
        Dosage in Renal InsufficiencyNo change
        +
        + +
        + + + + + + + + + + + + + + + +
        Safety in PregnancyAvoid
        Central Nervous System PenetrationGood (50-100%)
        Dosage in Renal InsufficiencyDecrease dose/ Increase interval
        +
        + +
        + + + + + + + + + + + + + + + +
        Safety in PregnancySafe
        Central Nervous System PenetrationInflamed meninges only (50-100%)
        Dosage in Renal InsufficiencyIncomplete data
        +
        + +
        + + + + + + + + + + + + + + + +
        Safety in PregnancyAvoid
        Central Nervous System PenetrationUnknown
        Dosage in Renal InsufficiencyProbably no change
        +

        Safe: Drug has not been demonstrated to have teratogenic effects.

        Avoid: Limited data on safety or for aminoglycosides associated with hearing impairment and/or @@ -103,36 +248,36 @@

        Do Not Use: Associated with premature labor, congenital malformations or teratogenicity.

        NOTES: Table 20 Special Situations

        -

        (1) As - with all medications given during pregnancy, anti-TB drugs should be used with caution. The risk of TB to - the - fetus far outweighs the risk of medications. Pregnant patients with active TB should be treated. Data are - limited on the safety of some anti-TB drugs during pregnancy. Table 20 presents a consensus of published - data - and recommendations. Although detailed teratogenic data is not available, PZA can probably be used safely - for - pregnant patients. Concentrations of anti-TB drugs in breast milk are low; treatment with these medications - is +

        (1) As with all medications given during pregnancy, anti-TB drugs should be used with caution. The risk of TB to + the fetus far outweighs the risk of medications. Pregnant patients with active TB should be treated. Data are + limited on the safety of some anti-TB drugs during pregnancy. Table 20 presents a consensus of published data + and recommendations. Although detailed teratogenic data is not available, PZA can probably be used safely for + pregnant patients. Concentrations of anti-TB drugs in breast milk are low; treatment with these medications is not a contraindication to breastfeeding. (Conversely, medication present in breast milk is not sufficient to - prevent or treat TB in the newborn.) Consult a medical expert when treating a pregnant patient who has TB. - For - treatment of LTBI, most authorities recommend beginning INH several months after delivery, unless the woman - is + prevent or treat TB in the newborn.) Consult a medical expert when treating a pregnant patient who has TB. For + treatment of LTBI, most authorities recommend beginning INH several months after delivery, unless the woman is at high risk for progression to active TB (e.g., recent TST or IGRA conversion, HIV-infected).

        -

        (2) Steroid treatment appears to improve outcome in TB meningitis, particularly in patients with altered - mental +

        (2) Steroid treatment appears to improve outcome in TB meningitis, particularly in patients with altered mental status.

        (3) If possible, monitor serum drug levels of patients with renal insufficiency. See page 71 for dosage.

        (4) Supplement with pyridoxine (Vitamin B6) during pregnancy.

        (5) Has been used intrathecally; efficacy not documented.

        (6) Avoid aminoglycosides and capreomycin in patients with reversible renal damage, if possible.

        (7) Fluoroquinolones may accumulate in renal failure and are poorly removed by dialysis. Dose adjustment - indicated. -

        + indicated.

        +
        + + diff --git a/app/src/main/assets/pages/table_21_grady_hospital_tb_isolation_policy.html b/app/src/main/assets/pages/table_21_grady_hospital_tb_isolation_policy.html index d496690..9d2f5ca 100644 --- a/app/src/main/assets/pages/table_21_grady_hospital_tb_isolation_policy.html +++ b/app/src/main/assets/pages/table_21_grady_hospital_tb_isolation_policy.html @@ -4,7 +4,7 @@ - + GA TB Reference Guide @@ -16,7 +16,9 @@
        -

        View in chapter -> Surveillance for Health Care Workers

        +

        View in chapter → Surveillance for Health Care Workers

        +

        Last Updated October 2025

        +
        @@ -43,7 +45,7 @@ - + diff --git a/app/src/main/assets/pages/table_2_interpretation_criteria_for_the_t_spot_tb_test.html b/app/src/main/assets/pages/table_2_interpretation_criteria_for_the_t_spot_tb_test.html index 99753e1..cf9de3b 100644 --- a/app/src/main/assets/pages/table_2_interpretation_criteria_for_the_t_spot_tb_test.html +++ b/app/src/main/assets/pages/table_2_interpretation_criteria_for_the_t_spot_tb_test.html @@ -4,7 +4,7 @@ - + GA TB Reference Guide @@ -15,51 +15,89 @@
        -

        View in chapter -> Interferon-y Release Assays (IGRAs)

        -
        -
        3. HIV+ patient admitted with abnormal CXR3. Person living with HIV admitted with abnormal CXR Until 2 sputum AFB smears are negative
        - - - - - - - - +

        View in chapter → Interferon-y Release Assays (IGRAs)

        +

        Last Updated October 2025

        +
        +
        +
        +
          +
          • +
          • +
          • +
          • +
        +
        + +
        InterpretationNil*TB Response†Mitogen§
        + + + + + + + + + + + + + + +
        Nil*≤ 10 spots
        TB Response†≥ 8 spots
        Mitogen§Any
        + + + + + + + + + + + + + + + + +
        Nil*< 10 spots
        TB Response†5, 6, or 7 spots
        Mitogen§Any
        + + - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - + + + + + + + + + + + +
        Positive¶≤ 10 spots≥ 8 spotsAny
        Borderline**≤ 10 spots5, 6, or 7 spotsAny
        Negative†† ≤ 10 spots>20 spots>20 spots
        Invalid**≤ 10 spotsAnyAny
        ≤ 10 spots<5 spots<20 spots
        Nil*≤ 10 spots
        TB Response†> 20 spots
        Mitogen§> 20 spots
        + + + + + + + + + + + + + + + + + + +
        Nil*≤ 10 spots≤ 10 spots
        TB Response†Any< 5 spots
        Mitogen§Any< 20 spots

        Source: Based on Oxford Immunotec T-Spot.TB package insert.
        @@ -89,4 +127,5 @@ + diff --git a/app/src/main/assets/pages/table_3_high_prevalence_and_high_risk_groups.html b/app/src/main/assets/pages/table_3_high_prevalence_and_high_risk_groups.html index 46728f5..395e07a 100644 --- a/app/src/main/assets/pages/table_3_high_prevalence_and_high_risk_groups.html +++ b/app/src/main/assets/pages/table_3_high_prevalence_and_high_risk_groups.html @@ -4,7 +4,7 @@ - + GA TB Reference Guide @@ -15,28 +15,29 @@

        -

        View in chapter -> Targeted Testing and Diagnostic Tests

        -
        +

        View in chapter → Targeted Testing and Diagnostic Tests

        +

        Last Updated October 2025

        +
        +
        - - + + - - + @@ -60,4 +61,4 @@ - \ No newline at end of file + diff --git a/app/src/main/assets/pages/table_4_recommendations_for_regimens_to_treat_latent_tuberculosis_infection.html b/app/src/main/assets/pages/table_4_recommendations_for_regimens_to_treat_latent_tuberculosis_infection.html index 7be6c67..a6b8fe9 100644 --- a/app/src/main/assets/pages/table_4_recommendations_for_regimens_to_treat_latent_tuberculosis_infection.html +++ b/app/src/main/assets/pages/table_4_recommendations_for_regimens_to_treat_latent_tuberculosis_infection.html @@ -4,7 +4,7 @@ - + GA TB Reference Guide @@ -15,55 +15,64 @@
        -

        View in chapter -> Treatment Regimens for LTBI

        -
        -
        Groups with a High Prevalence of Latent TB Infection Groups with a High Risk of Progression to Active TB Disease if Infected with M. - tuberculosisGroups With a High Prevalence of Latent TB Infection Groups With a High Risk of Progression to Active TB Disease if Infected with M. tuberculosis
        Persons born in countries with high rates of TBPersons living with HIV Persons who are close contacts of persons with infectious active TB + Persons living with HIV Persons who are close contacts of persons with infectious active TB 
        Groups with poor access to healthcareChildren less than 5 years of ageChildren less than 6 years of age
        Persons who live or spend time in certain facilities (e.g., nursing homes, correctional institutions, - homeless shelters, drug treatment centers) + homeless shelters, drug treatment centers)  Persons with recent infection with M. tuberculosis (e.g., have had a diagnostic test result for LTBI convert to positive in the past 1-2 years) Persons who have chest radiographs suggestive of old TB @@ -48,8 +49,8 @@
        *Diabetes mellitus, silicosis, prolonged therapy with corticosteroids, immunosuppressive - therapy particularly TNF-α blockers, leukemia, Hodgkin’s disease, head and neck cancers, - severe kidney disease, certain intestinal conditions, malnutrition + therapy particularly TNF-α blockers, leukemia, Hodgkin’s disease, head and neck cancers, + severe kidney disease, certain intestinal conditions, malnutrition 
        - - - - - - - - +

        View in chapter → Treatment Regimens for LTBI

        +

        Last Updated October 2025

        +
        +
        +
        +
          +
          • +
          • +
        +
        + +
        Priority rank* RegimenRecommendation (strong or conditional)Evidence (high, moderate, low, or very low)
        - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - + + + + + + + + + + + + + + + + + +
        Preferred3 mos isoniazid plus rifapentine given once weeklyStrongModerate
        4 mos rifampin given dailyModerate (HIV negative)†
        3 mos isoniazid plus rifampin given dailyConditionalVery low (HIV negative)
        Low (HIV positive)
        Alternative6 mos isoniazid given dailyStrong§Moderate (HIV negative
        ConditionalModerate (HIV positive)
        9 mos isoniazid given dailyModerate
        Regimes3 months isoniazid plus rifapentine given once weekly4 months rifampin given daily3 months isoniazid plus rifampin given daily
        Recommendation (Strong or Conditional)StrongStrongConditional
        Evidence (High, Moderate, Low, or Very Low)ModerateModerate (HIV negative) † Very low (HIV negative) †
        - + + + + + + + + + + + + + + + + + + + + + +
        Regimes6 months isoniazid given daily9 months isoniazid given daily3 months isoniazid plus rifampin given daily
        Recommendation (Strong or Conditional)Strong §ConditionalConditional
        Evidence (High, Moderate, Low, or Very Low)Moderate (HIV negative)Moderate (if living with HIV)Moderate
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        Abbreviation: HIV = human immunodeficiency virus
        * Preferred: excellent tolerability and efficacy, shorter treatment duration, higher completion rates than longer regimens, and therefore higher @@ -78,4 +87,5 @@ + diff --git a/app/src/main/assets/pages/table_5_dosages_for_recommended_lbti_treatment_regimens.html b/app/src/main/assets/pages/table_5_dosages_for_recommended_lbti_treatment_regimens.html index 295cf0c..b56a9a3 100644 --- a/app/src/main/assets/pages/table_5_dosages_for_recommended_lbti_treatment_regimens.html +++ b/app/src/main/assets/pages/table_5_dosages_for_recommended_lbti_treatment_regimens.html @@ -4,7 +4,7 @@ - + GA TB Reference Guide @@ -15,124 +15,149 @@

        -

        View in chapter -> Treatment Regimens for LTBI

        - - + + diff --git a/app/src/main/assets/pages/table_6_ltbi_treatment_drug_adverse_reactions.html b/app/src/main/assets/pages/table_6_ltbi_treatment_drug_adverse_reactions.html index f74ae72..869e26f 100644 --- a/app/src/main/assets/pages/table_6_ltbi_treatment_drug_adverse_reactions.html +++ b/app/src/main/assets/pages/table_6_ltbi_treatment_drug_adverse_reactions.html @@ -4,7 +4,7 @@ - + GA TB Reference Guide @@ -15,83 +15,97 @@
        -

        View in chapter -> Treatment Regimens for LTBI

        -
        - - - - - - - - - +

        View in chapter → Treatment Regimens for LTBI

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        Last Updated October 2025

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        DrugAdverse ReactionsMonitoringComments
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        Adverse Reactions + Gastrointestinal (GI) upset, hepatic enzyme elevations, hepatitis, peripheral neuropathy, mild effects on central nervous system (CNS), drug interactions +
        + Monitoring + + Order baseline hepatic chemistry blood tests (at least AST or ALT) for patients with specific conditions: Living with HIV, liver disorders, postpartum period (<3 months after delivery), regular alcohol use, injection drug use, or use of medications with known possible interactions. [Some clinicians prefer to obtain baseline tests on all adults]. Repeat measurements if: * baseline results are abnormal * client is at high-risk for adverse reactions * client has symptoms of adverse reactions +
        + Comments + + Hepatitis risk increases with age and alcohol consumption. Pyridoxine can prevent isoniazid-induced peripheral neuropathy. +
        + + + + + + + + + + + + + + + + +
        Adverse Reactions + Orange discoloration of body fluids (secretions, tears, urine) , GI upset, drug interactions, hepatitis, thrombocytopenia, rash, fever, influenza-like symptoms, hypersensitivity reaction* Many drug-drug interactions +
        + Monitoring + + Complete blood count (CBC), platelets and liver function tests. + Repeat measurements if: * baseline results are abnormal * client has symptoms of adverse reactions  Prior to starting RIF or RPT: need to carefully review all medications being taken by the patient with LTBI and ensure there is no contraindication to the use of that medication and RIF, RBT or RPT. +
        + Comments + + Hepatitis risk increases with age and alcohol consumption. Rifampin monotherapy is associated with lower risk of hepatotoxicity compared to INH monotherapy for patients being treated for LTBI. Need to carefully review for possible drug-drug interactions prior to starting RIF, RBT or RPT and ensure there are no contraindications to these agents prior to using them for the treatment of LTBI.
        + + - - - - - - - - - - - - - - - - - - + + + + + + + + + + + +
        Isoniazid (INH)Gastrointestinal (GI) upset, hepatic enzyme elevations, hepatitis, peripheral - neuropathy, mild effects on central nervous system (CNS), drug interactions - Order baseline hepatic chemistry blood tests (at least AST or ALT) for patients with the following - specific conditions: HIV infection, liver disorders, postpartum period (≤ 3 months after - delivery), regular alcohol use, injection drug use, or use of medica-tions with known possible inter - -actions.
        -
        - [some providers prefer to obtain baseline tests on all adults].
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        - Repeat measurements if: * baseline results are abnormal * client is at high-risk for adverse - reactions * client has symptoms of adverse reactions -         		Hepatitis risk increases with age and alcohol consumption. Pyridoxine can prevent isoniazid-induced - peripheral neuropathy. -
        Rifampin (RIF) and Rifapentine (RPT)Orange discoloration of body fluids (secretions, tears, urine) , GI upset, drug - interactions, hepatitis, thrombocytopenia, rash, fever, influenza-like symptoms, hypersensitivity - reaction* Many drug-drug interactionsComplete blood count (CBC), platelets and liver function tests.
        - Repeat measurements if: * baseline results are abnormal * client has symptoms of adverse - reactions Prior to starting RIF or RPT: need to carefully review all medications - being taken by the patient with LTBI and ensure there is no contraindication to the use of that - medication and RIF or RPT. -         		Hepatitis risk increases with age and alcohol consumption. Rifampin monotherapy is associated with - lower risk of hepatotoxicity compared to INH monotherapy for patients being treated for LTBI. Need - to carefully review for possible drug-drug interactions prior to starting RIF or RPT and ensure - there are no contraindications to these agents prior to using them for the treatment of LTBI. -
        Isoniazid plus rifapentine (3HP)See adverse effects associated with isoniazid alone and a rifamycin alone (see above) See above recommendations for isoniazid and rifamycin drugsApproximately 4% of all patients using 3HP experience flu-like or other systemic drug reactions, - with fever, headache, dizziness, nausea, muscle and bone pain, rash, itching, red eyes, or other - symptoms. Approximately 5% of persons discontinue 3HP because of adverse events, including systemic - drug reactions; these reactions typically occur after the first 3–4 doses, and begin - approximately 4 hours after ingestion of medication. -
        Adverse ReactionsSee adverse effects associated with isoniazid alone and a rifamycin alone (see above)
        MonitoringComplete blood count (CBC), platelets and liver function tests. + Repeat measurements if: * baseline results are abnormal * client has symptoms of adverse reactions  Prior to starting RIF or RPT: need to carefully review all medications being taken by the patient with LTBI and ensure there is no contraindication to the use of that medication and RIF or RPT.
        CommentsApproximately 4% of all patients using 3HP experience flu-like or other systemic drug reactions, with fever, headache, dizziness, nausea, muscle and bone pain, rash, itching, red eyes, or other symptoms. Approximately 5% of persons discontinue 3HP because of adverse events, including systemic drug reactions; these reactions typically occur after the first 3–4 doses, and begin approximately 4 hours after ingestion of medication.

        - * Hypersensitivity reaction to rifamycins (rifampin or rifapentine): reactions may - include a flu-like syndrome (e.g. fever, chills, headaches, dizziness, musculoskeletal pain), - thrombocytopenia, shortness of breath or other signs and symptoms including wheezing, acute bronchospasm, - urticaria, petechiae, purpura, - pruritus, conjunctivitis, angioedema, hypotension or shock. If moderate to - severe reaction (e.g. thrombocytopenia, hypotension), hospitalization or lifethreatening event: Discontinue - treatment. If mild reaction (e.g. rash, dizziness, - fever): Continue to monitor patient closely with a low threshold for discontinuing treatment. A flu-like - syndrome appears to be the most common side effect - profile leading to discontinuation of the 3HP regimen. + * Hypersensitivity reaction to rifamycins (rifampin, rifabutin, rifapentine): reactions may include a flu-like syndrome (e.g. fever, chills, headaches, dizziness, musculoskeletal pain), thrombocytopenia, shortness of breath or other signs and symptoms including wheezing, acute bronchospasm, urticaria, petechiae, purpura, pruritus, conjunctivitis, angioedema, hypotension or shock. If moderate to severe reaction (e.g. thrombocytopenia, hypotension), hospitalization or life-threatening event: Discontinue treatment. If mild reaction (e.g. rash, dizziness, fever): Continue to monitor patient closely with a low threshold for discontinuing treatment. A flu-like syndrome appears to be the most common side effect profile leading to discontinuation of the 3HP regimen. Rifabutin can rarely cause uveitis.

        + diff --git a/app/src/main/assets/pages/table_7_recommended_regimens_for_treatment_of_adults_and_children_with_drug_susceptible_tb_pulmonary_tb.html b/app/src/main/assets/pages/table_7_recommended_regimens_for_treatment_of_adults_and_children_with_drug_susceptible_tb_pulmonary_tb.html index 5ee3387..a85677d 100644 --- a/app/src/main/assets/pages/table_7_recommended_regimens_for_treatment_of_adults_and_children_with_drug_susceptible_tb_pulmonary_tb.html +++ b/app/src/main/assets/pages/table_7_recommended_regimens_for_treatment_of_adults_and_children_with_drug_susceptible_tb_pulmonary_tb.html @@ -4,7 +4,7 @@ - + GA TB Reference Guide @@ -16,54 +16,96 @@
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        View in chapter -> Special Clinical Situations

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        View in chapter → Special Clinical Situations

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        Last Updated October 2025

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