This guideline will simplify the process of latent TB chemoprophylactic treatment consideration. It outlines the pathway for treatment, monitoring and steps if treatment is deferred.

Overview

Patients with inactive TB infection are asymptomatic. However, without treatment they can develop active TB disease and become sick. Anyone can get infected with TB bacteria, but some people are at higher risk. Those are people born in or frequently travelling to countries of high TB prevalence for more than 6 months, those with recent, close contact with someone with active TB disease, healthcare workers and people who are immunosuppressed. Therefore, screening for latent TB is required so that prophylactic treatment can be given to reduce the risk of reactivation to active disease.

Guideline

The following patients will be reviewed in the TB clinic for consideration of TB chemoprophylaxis:

• Migrants from high incidence areas with a positive Interferon- gamma test (IGRA) / Mantoux (≤65 years old)

• HIV-positive patients with a positive IGRA or Mantoux (any age)

• Patients considered for biologic treatment with a positive IGRA (any age)

• Others: Healthcare Workers (any age), patients ≤65 years with a positive IGRA

It is imperative to ask the patient about active TB symptoms and organise the necessary investigations if symptoms are present. Active TB symptoms to exclude are: loss of appetite, weight loss, fever, drenching night sweats, cough >3 weeks, lymph node or soft tissue swelling, other site specific symptoms (e.g. spinal/abdominal symptoms).

Clinicians assessing patients for active TB should refer patients to the TB team if they are symptomatic or have an abnormal chest x-ray with changes suspicious for TB infection. If they have a productive cough then 3 sputum samples should be sent for AFB smear and AFB culture and 1 for TB PCR (for PCR please email the microbiology team to ask for this to be processed giving the clinical information and use the email address ). If patients have a past history of tuberculosis infection or latent TB treatment, then screening for active TB infection is only required with a CXR - as IGRA is unhelpful as it often remains positive.

Offer TB chemoprophylaxis with:-

• 3 months RIF/INH or

• 6 months INH (for patients on drugs that interact with Rifampicin e.g. protease inhibitors, oral contraceptive pill) or

• 4 months Rifampicin

(Check FBC, U&E & LFT and hepatitis B, C and HIV tests pre-treatment).

Monthly follow-up contact is organized with TB nurses to check compliance. Checks of LFT are also arranged in some patients when clinically indicated.

Assessment for active TB must be initially completed, and if symptomatic a CXR must be done with the patient’s consent (using lead shielding of the abdomen if pregnant). If the patient is asymptomatic, the CXR will be deferred until after delivery. The TB nurses will counsel the patient on active TB signs and symptoms, and they will arrange a post-partum CXR soon after delivery (if pregnant). The TB nurses will also contact the patient every 2 months to check for new symptoms and evidence of TB disease reactivation. This surveillance will continue until the patient has finished breastfeeding and TB chemoprophylaxis is given.

A CXR will be organized (if not done within 3 months) and the patient reassessed for signs and symptoms of active TB infection. Latent TB treatment will then be commenced if they are not breastfeeding. If breastfeeding, the TB nurses will continue 2 monthly surveillance until the chemoprophylaxis is given.

REVIEW IN TB CLINIC FOR CONSIDERATION OF CHEMOPROPHYLAXIS:

• Migrants from high incidence areas with a positive IGRA/Mantoux < 65yrs

• HIV-positive patients with a positive IGRA or Mantoux

• Patients considered for anti-TNF treatment with a positive IGRA (any age)

• Others: Healthcare Workers (any age) with positive IGRA

World Health Organization (2023) Global tuberculosis report 2023. Available at: https://www.who.int/teams/global-tuberculosis-programme/tb-reports/global-tuberculosis-report-2023 (Accessed: 20 May 2024).

National Institute for Health and Care Excellence [NICE] (2024) Tuberculosis. NG33. Available at: https://www.nice.org.uk/guidance/ng33 (Accessed: 20 May 2024)

Public Health England and NHS England (2015) Collaborative tuberculosis strategy for England 2015 to 2020. Available at: https://www.gov.uk/government/publications/collaborative-tuberculosis-strategy-for-england (Accessed: 20 May 2024).

UK Health Security Agency (2022) Tuberculosis by country: rates per 100,000 people. Available at: https://www.gov.uk/government/publications/tuberculosis-tb-by-country-rates-per-100000-people (Accessed: 20 May 2024).

National latent tuberculosis infection testing and treatment programme. Available at: NHS England » National latent tuberculosis infection testing and treatment programme (Accessed: 21 May 2024)

This guideline has been registered with the Trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt, contact a senior colleague or expert. Caution is advised when using guidelines after the review date.

This guideline is for use in Frimley Health NHS Foundation Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

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