Self-Study Modules 

on Tuberculosis 

Treatment of Latent 

Tuberculosis Infection

and Tuberculosis 

Disease 

Module 4: Objectives 

At completion of this module, learners will be able to: 

1.	 List groups of people who should receive high 

priority for latent TB infection (LTBI) treatment 

2.	 Describe treatment regimens for LTBI 

3.	 Describe treatment regimens for TB disease 

4.	 Describe principles of preventing drug resistance 

5.	 Describe patient monitoring during LTBI and TB 

disease treatment 

6.	 Describe TB treatment adherence strategies 

7.	 List common adverse reactions to drugs used to 

treat LTBI and TB disease Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 

Module 4: Overview 

• Treatment of LTBI 

– Patient Medical Evaluation 

– LTBI Treatment Regimens 

– Special Considerations for LTBI Treatment 

• Treatment of TB Dis ease 

– TB Disease Treatment Regimens 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 3 

Module 4: Overview (cont.) 

• Treatment of TB Dis ease (cont.) 

– Special Considerations and Alternative
 

Treatment Regimens
 

– Treatment and M onitoring Plan and A dverse 

Reactions 

– Adherence and Evaluating Patients’
 

Response to Treatment
 

– Role of Public Health Workers 

• Case Studies 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 

Treatment of Latent TB

Infection (LTBI) 

Treatment of LTBI (1) 

• LTBI is treated to prev ent the development of 

TB disease 

• LTBI is treated with medication 

5 Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease
 

1
 

2 

4 

6 
Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 8 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 10 

Treatment of LTBI (2)
 

•	 Targeted testing should be used to ide ntify and 

treat people who are: 

– At high risk for exposure to or infec tion with 

M. tuberculosis 

– At high risk for developing TB disease once 

infected with M. tuberculosis 

•	 People in these groups should receive high 

priority for LTBI treatment if they have a 

positive tuberculin skin test (TST) or interferongamma release assay (IGRA) 

7 

High Priority for LTBI Treatment (1) •	 High-priority groups for LTBI tre atment if pos itive 

IGRA or TST result of > 5 mm 

– Recent contacts of people with infectious TB 

disease 

– People living with HIV 

– People with chest x-ray findings suggestive of 

previous TB disease 

– Patients with an organ tra nsplant 

– Other immunosuppressed patients 

High Priority for LTBI Treatment (2) 

•	 High-priority groups for LTBI tre atment if positive IGRA or TST re sult of > 10 mm: 

– People who have come to U.S. from
 

countries where TB is common
 

– People who abuse drugs 

– People who live or work in high-risk
 

congregate settings
 

– People who work in mycobacteriology
 

laboratories
 

High Priority for LTBI Treatment (3) 

Treatment of Latent TB
 

Infection (LTBI)
 

Patient Medical Evaluation
 

•	 High-priority groups for LTBI tre atment if pos itive 

IGRA or TST result of > 10 mm (cont.): 

– People with medical conditions that increase 

risk of TB dis ease 

– Children younger than 5 years of age 

– Infants, children, and adolescents exposed to 

adults in high-risk groups 

Low Priority for LTBI Treatment 

•	 Individuals without any risk factors generally 

should not be tested for TB infection 

•	 However, individuals with no risk factors who 

are tested and have a positive IGRA or TST 

result of > 15 mm should be evaluated for LTBI 

treatment 

9 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 11 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease
 

2
 

12 
Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 13 Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 14 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 15 Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 16 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 17 Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 18 

Patient Medical Evaluation (1) Patient Medical Evaluation (2)


Medical evaluations should be done to: 

1.	 Exclude possibility of TB dis ease 

2.	 Determine whether patient has ever been
 

treated for TB infe ction or TB disease
 

3.	 Find out if patient ha s any medical conditions 

that may complicate therapy 

4.	 Establish and build rapport w ith patient 

Patient Medical Evaluation (3) 

2.	 Determine whether patient has ever been 

treated for TB infe ction or TB disease 

•	 Patients who have been adequately 

treated should not be treated again 

•	 TST or IGRA results cannot determine if 

patient has received treatment for LTBI or 

TB disease; or if they have been reinfected after treatment 

Patient Medical Evaluation (4) 

3.	 Find out if patie nt has any medical conditions 

that may complicate therapy or require more 

careful monitoring. These patients include: 

• People living with HIV 

• People with history of liver disorder or disease 

• People who use alcohol regularly 

• Women who are pregnant or just had a baby 

(within 3 months of delivery) 

• People who are taking other medications that may 

increase the risk of hepatitis 

1. Exclude possibility of TB disease 

• Treating TB disease with LTBI treatment regimen 

can lead to drug resistance 

• Clinicians should determine if the patient has 

symptoms of TB disease 

• Clinicians should evaluate the patient with a chest 

x-ray 

• Patients with symptoms or chest x-ray findings of 

TB disease should be given TB disease treatment, 

not LTBI treatment 

Patient Medical Evaluation (5) 

For patients with the medical conditions listed 

on the previous slide, baseline laboratory liver 

function tests (to detect injury to liver) are 

recommended before starting LTBI trea tment. 

Patient Medical Evaluation (6) 

•	 It is important to find 

out if: 

– Patient has ever had 

adverse reactions to 

LTBI drugs 

– Patient is currently 

on medications that 

may interact with 

LTBI drugs 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease


3
 
Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 19 Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 20 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 22 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 23 Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 24 

Patient Medical Evaluation (7) 

4. Establish and build rapport w ith patient 

• Health care workers (HCWs) should 

highlight important a spects of treatment, 

such as: 

–Benefits of treatment 

–Importance of adherence to treatment 

–Possible adverse reactions 

–Establishment of a follow-up plan 

LTBI Treatment Regimens (1)
 

Isoniazid
 

•	 Isoniazid (INH) daily for 9 months is very effective in 

preventing the development of TB disease 

•	 INH may also be given for 6 months 

– Cost effective and patients may find it easier to 

adhere, BUT: 

• Not as effective if given for less than 6 months 

• Not recommended for people living with HIV, 

individuals with previous TB disease, or 

children 

LTBI Treatment Regimens (2) 

Isoniazid and Rifapentine (12-Dose Regimen) 

•	 Combination of INH and rifapentine (RPT) given in 12, once-aweek doses under DOT, if possible 

•	 Recommended for patients who: 

– Are 12 years of age or older 

– Were recently exposed to infectious TB 

– Have a TST or IGRA conversion from negative to positive 

– Have chest x-ray findings of previous TB disease 

•	 Regimen may be used in otherwise healthy HIV-infected 

persons who are: 

– 12 years of age or older 

–	 Not on antiretroviral therapy (ART), except those taking an 

efavirenz or raltegravir-based ART regimen 

LTBI Treatment Regimens (3) 

Isoniazid and Rifapentine (12-Dose Regimen) 

•	 This regimen is not recommended for 

– Children younger than 2 years of age 

– People with HIV/AIDS who are taking certain ART 

regimens 

– People presumed to be infected with isoniazid or 

rifampin-resistant M. tuberculosis 

– Pregnant women or women expecting to 

become pregnant within the 12–week regimen 

Patient Medical Evaluation (8) 

Because of the interaction between TB and HIV, 

HCWs should also recommend that patie nts 

undergo HIV counseling and testing 

Treatment of Latent TB


Infection (LTBI)
 

LTBI Treatment Regimens 

21 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease
 

4
 
Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 25 Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 26 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 27 Table 4.2

Drug Duration Frequency Minimum Comments 

(months) Dose 

INH 9 Daily 270 1. Preferred regimen is daily 

treatment for 9 months 

Twice 76 

weekly 2. DOT must be used with 

twice-weekly dosing 

INH 6 Daily 180 1. NOT recommended for 

people living with HIV, 

Twice 52 children, or people with 

weekly chest x-rays suggestive of 

previous TB disease 

2. DOT must be used with 

twice-weekly dosing 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 28 

Drug Duration 

(months) 

Frequency Minimum
 

Dose
 

Comments 

INH 

and 

RPT 

3 Once
 

Weekly
 

12 1.	 

2. 

NOT recommended for children 

younger than 2 years of age, HIVinfected patients taking certain ART 

regimens, patients with resumed INH 

or RIF-resistant TB, pregnant women, 

or women expecting to become 

pregnant 

DOT is recommended, if possible 

RIF
 4 Daily
 120 1.	 

2.	 

Recommended for patients who have 

INH-resistant TB 

NOT recommended for HIV-infected 

patients on certain combinations of 

ART. RFB may be used instead for 

some patients. 

RIF/
 

PZA
 

Due to the reports of severe liver injury and deaths, RIF and PZA combinations 

generally should not be offered for treatment of LTBI 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 29 

Treatment of LTBI 

Study Question 4.1 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 30 

Treatment of LTBI
 

Study Question 4.2


LTBI Treatment Regimens (4)


Rifampin
 

•	 Rifampin (RIF) is also recommended for people with 

a positive TST or IGRA result 

– Especially if the person has been exposed to INHresistant TB 

•	 RIF should be given daily for 4 months 

•	 RIF should not be used with certain combinations of 

ART 

•	 In some cases, rifabutin (RFB) may be substituted 

when RIF cannot be used 

LTBI Treatment Regimens (5)
 

Rifampin and Pyrazinamide
 

•	 CDC advises against using a combination of 

RIF and pyrazinamide (PZA) due to serious 

side effects such as: 

– Severe liver injury 

– Death 

LTBI Treatment Regimens (6)
 LTBI Treatment Regimens (7)
 

What is the purpose of LTBI tre atment? Which groups of people should receive highpriority for LTBI treatment if the y have a positive 

IGRA or TST result of > 5 mm? Name 5. 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease
 

5
 
Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 31 

Treatment of LTBI 

Study Question 4.3 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 32 

LTBI Treatment Regimens 

Study Question 4.4 


 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 34 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 35 Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 36 

Which groups of people should receive high 

priority for LTBI treatment if they have a positive 

IGRA result or a TST reaction that is > 10 mm? 

Name 7. 

List 4 regimens that are approved for the 

treatment of LTBI. 

Treatment of Latent TB
 

Infection (LTBI)
 

Special Considerations for LTBI

Treatment
 

Special Considerations for LTBI (1) 

Directly Observed Therapy (DOT) 

•	 DOT is when a HCW or another designated 

person watches a patient swallow each dose of 

medication 

– Used to he lp patients adhere to treatment 

– Should be considered for people who are at 

high risk for TB or suspe cted to be nonadherent 

– Recommended for inte rmittent therapy 

33 

Special Considerations for LTBI (2) 

Contacts 

•	 Contacts are people who have been exposed to 

someone with infectious TB disease 

•	 Contacts should be quickly identified, located, 

and assessed for LTBI and TB dise ase 

– If TST or IGRA result is positive, contacts 

should be given high priority for LTBI 

treatment (once TB disease is ruled out) 

– If TST or IGRA result is negative, contacts 

should be retested in 8 to 10 weeks 

Special Considerations for LTBI (3) 

Contacts 

•	 In general, contacts with positive test result 

and a documented history of completion of 

LTBI treatment do not ne ed to be retreated 

•	 However, retreatment may be necessary for 

persons at high ris k of: 

– Becoming re-infected 

– Progressing to TB dise ase 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease
 

6
 
Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 37 Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 38 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 39 Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 40 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 41 Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 42 

Special Considerations for LTBI (4) 

Contacts at High Risk for Rapid D evelopment of
 

TB Disease
 

•	 Some contacts may be started on LTBI treatment 

even if their test result is negative, and less than 8 to 

10 weeks have passed since last exposure to TB; this 

includes: 

– Children younger than 5 years of age 

– People living with HIV 

•	 Expert consultation should be sought to determine if 

contacts with immunocompromised states other than 

HIV infection could benefit from treatment even if 

they have a negative TST or IGRA result 

Special Considerations for LTBI (5) 

Contacts at High Risk for Rapid D evelopment of
 

TB Disease
 

•	 Once active TB disease is ruled out, c ontacts at 

high risk for TB dis ease should: 

– Start LTBI treatment 

– Be retested 8 to 10 weeks after last exposure to TB 

• If negative test result: stop LTBI treatment 

• If positive test result: continue LTBI treatment 

•	 Contacts living with HIV may be given full course 

of LTBI treatment even if their se cond TST or 

IGRA result is negative 

Special Considerations for LTBI (6) 

Infants and Children 

•	 Infants and children a re more likely to develop 

life-threatening forms of TB dis ease 

•	 Children younger than 5 years of age who have 

been exposed to TB s hould start tak ing LTBI 

treatment even if they have a negative TST or 

IGRA result because they: 

– Are at high ris k for rapidly developing TB
 

disease
 

– May have a false-negative TST reaction 

Special Considerations for LTBI (7) 

Infants and Children 

•	 Infants and children should be retested 8 to 10 weeks 

after last exposure 

•	 LTBI treatment can be stopped if ALL of the following 

conditions are met: 

– Child is at least 6 months of age 

– Second TST or IGRA is negative 

– Second TST or IGRA was done at least 8 weeks after 

child was last exposed to a person with infectious TB 

disease 

•	 The 12-dose regimen is not recommended for children 

younger than 2 years of age 

Special Considerations for LTBI (8) 

Contacts of INH-Resistant TB 

•	 Contacts of patients with INH-resistant, but RIFsusceptible TB, may be treated with a 4-month 

daily regimen of RIF 

•	 In some patients, rifabutin (RFB) may be 

substituted if RIF cannot be used 

Special Considerations for LTBI (9) 

Contacts of Multidrug-Resistant TB (MDR TB) 

•	 The risk for developing TB disease should be considered 

before recommending LTBI treatment 

•	 Contacts of patients with MDR TB 

– May be treated for 6 to 12 months with an alternative 

regimen of drugs to which the M. tuberculosis isolate is 

susceptible 

– Can be observed for signs and symptoms of TB
 

disease without treatment
 

•	 All persons with suspected MDR LTBI should be followed 

and observed for signs and symptoms of TB disease for 2 

years, regardless of the treatment regimen 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease
 

7
 
Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 43 Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 44 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 45 Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 46 

LTBI Treatment Regimens
 

Study Question 4.5
 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 47 

Special Considerations for LTBI


Study Question 4.6
 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 48 

Special Considerations for LTBI


Study Question 4.7
 

Special Considerations for LTBI (10)
 

Pregnant Women 

Special Considerations for LTBI (11)
 

Breastfeeding Women 

•	 For most pregnant women, LTBI treatment can be 

delayed until after delivery, unless they have 

certain risk factors 

•	 Immediate treatment should be considered if 

woman is living with HIV or is a recent TB contact 

•	 Preferred LTBI treatment regimen is 9 months of 

INH with a vitamin B6 supplement 

– INH has not been shown to have harmful
 

effects on the fetus
 

•	 The 12-dose regimen is not recommended for 

pregnant women or women expecting to become 

pregnant within the 12-week regimen 

•	 Women who are 

breastfeeding can take 

INH, but should a lso be 

given a vitamin B6 

supplement 

•	 Amount of INH in 

breast milk is not 

enough to be 

considered treatment 

for infant 

In what circumstances may LTBI treatment 

be given to people who have a negative TST 

or IGRA result? 

What conditions must be met to stop LTBI 

treatment for childre n who are younger than 5 

years of age and have been exposed to TB? 

Special Considerations for LTBI (12) 

People Living with HIV 

•	 Individuals living with HIV should be treated with 9-month 

regimen of INH 

•	 RIF should not be used for people who are taking certain 

combinations of ART 

– Dose-adjusted rifabutin (RFB) may be given 

•	 The 12-dose regimen of INH and RPT may be used for 

people living with HIV who are: 

– 12 years of age or older 

– Not on ART, except those taking an efavirenz or
 

raltegravir-based ART regimen
 

What LTBI treatment regimen may be 

recommended for people with a positive TST 

or IGRA result w ho have been exposed to 

INH-resistant TB? 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease
 

8
 
Special Considerations for LTBI

Study Question 4.8
 


 

Adverse Reactions and Patient
 

Monitoring
 

When should pregnant women be treated for 

LTBI and for how long? Treatment of Latent TB
 

Infection (LTBI)
 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 49 

Adverse Reactions to INH (3)
 

Hepatitis
 

•	 INH can cause hepatitis in anyone; however, 

hepatitis occurs in less than 1% of pe ople 

taking INH 

•	 Certain risk factors increase the risk of 

serious hepatitis, such as: 

– Older age 

– Alcoholism 

Adverse Reactions to INH (1) 

•	 About 10% to 2 0% of pe ople treated with INH 

will have mild, abnormal liver test results 

during treatment 

– In most people, liver test results return to 

normal 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 51 

Adverse Reactions to INH (2)
 

Hepatitis
 

•	 A major risk of INH is hepatitis (inflammation of the liver) 

•	 Hepatitis prevents the liver from functioning 

normally, causing symptoms such as: 

– Nausea 

– Vomiting 

– Abdominal pain 

– Fatigue 

– Brown urine 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 

Adverse Reactions to INH (4)
 

Peripheral Neuropathy
 

•	 INH can cause peripheral neuropathy 

– Damage to sensory nerves of hands and feet 

– Symptoms include a tingling sensation, weakened 

sense of touch, or pain in the hands, palms, soles 

and feet 

•	 HIV, alcoholism, diabetes, and malnutrition increase 

risk for peripheral neuropathy 

– People with these conditions should be given 

vitamin B6 Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 53 Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease
 

9


50 

52 

54 
Adverse Reactions to RIF, RPT, and RFB Adverse Reactions to RPT and RFB
 

•	 Hepatitis is more likely to occur when RIF is combined with INH 

•	 Other side effects of RIF, RPT, and RFB inc lude: 

– Rash 

– Gastrointestinal symptoms 

– Orange discoloration of urine, saliva, and tears 

– Interaction with many other drugs, such as birth control

pills and implants, warfarin, some HIV drugs, and 

methadone 

– Hypersensitivity 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 55 

Adverse Reactions 

•	 Patients should be instructed to report any signs and 

symptoms of adverse drug reactions to their health care provider 

•	 Patients should stop taking the medication and seek 

medical attention immediately if symptoms of serious 

adverse reactions occur 

– No appetite 

– Nausea 

– Vomiting 

– Yellowish skin or eyes 

– Fever for 3 or more days 

– Abdominal pain 

– Tingling in fingers and toes 

– Brown urine 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 57 

Patient Monitoring (1) 

•	 All persons taking LTBI treatment should be 

educated about symptoms caused by adverse 

reactions 

•	 Patients need to be evaluated at least monthly 

during therapy for: 

– Adherence to prescribed regimen 

– Signs and symptoms of TB dis ease 

– Adverse reactions 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 

•	 RPT may cause flu-like symptoms 

•	 RFB may cause 

– Eye inflammation 

– Joint pain 

– Lower white blood cell count 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 

Patient Monitoring (2) 

•	 During each monthly evaluation, patients should 

be: 

– Asked whether they have nausea, abdominal 

pain, or other s ymptoms of adverse reactions 

– Examined by HCW for adv erse reactions 

– Instructed to stop medications and contact 

HCWs immediately if they have signs or 

symptoms of hepatitis 

Patient Monitoring (3) 

•	 People at greatest risk for hepatitis should have 

baseline liver function tests before starting LTBI treatment and every month during thera py. This 

includes: 

– People living with HIV 

– People with history of liver disorder or disease 

– People who use alcohol regularly 

– Women who are pregnant or just had a baby 

– People taking medications that may increase risk 

of hepatitis 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 59 Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease


10
 

56 

58 

60 
Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 61 Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 62 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 63 

Medical Evaluation
 

Study Question 4.9
 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 64 

LTBI Treatment
 

Study Question 4.10


Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 65 

Adverse Reactions 

Study Question 4.11 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 66 

Adverse Reactions
 

Study Question 4.12


Patient Monitoring (4)
 LTBI Treatment Follow-Up
 

•	 For all patients, INH, RIF, and RPT s hould be 

stopped if liv er function test results are: 

– 3 times higher than uppe r limit of the normal 

range and patient has symptoms 

OR 

– 5 times higher than uppe r limit of the normal

range and patient has no symptoms 

•	 Patients should receive documentation of TST 

or IGRA results , treatment regimens, and 

treatment completion dates 

– Patients should present these documents 

any time they are required to be tested for TB 

infection 

•	 Patients should be re-educated about signs 

and symptoms of TB dis ease 

What are the symptoms of hepatitis? Who is at greatest risk for hepatitis? What 

special precautions should be taken for thes e 

patients? 

Name 4 reasons why patients should receive a 

medical evaluation before starting LTBI 

treatment. 

Why is it important to ex clude the possibility 

of TB dise ase before giving a patient LTBI 

treatment? 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease
 

11
 
Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 67 

Adverse Reactions 

Study Question 4.13 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 69 Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 70 

• First 8 weeks of treatment 

Intensive Phase • Most bacilli killed dur 

• 4 drugs used 

ing this phase 

• After first 8 weeks of TB disease 

Continuation 

Phase 

treatment 

• Bacilli remaining after intensive 

phase are treated with at least 2 

drugs 

• Occurs when treatment is not 

Relapse continued for long enough 

• Surviving bacilli may cause TB 

disease at a later time 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 71 Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 72 

How often should pa tients be evaluated for 

signs and symptoms of adverse reactions 

during LTBI trea tment? Treatment of TB Disease
 

Treatment of TB D Treatment of TB Disease (2)
 isease (1) 

•	 Treating TB dise ase benefits both the person

who has TB and the community 

– Patient: prevents disability and death;
 

restores health
 

– Community: prevents further transmission 

of TB 

•	 TB disease must be treated for a t least 6 

months; in some cases, treatment lasts longer 

Treatment of TB Disease (4) 

•	 Treatment must c ontain multiple drugs to 

which organisms are susceptible 

•	 Treatment with a single drug can lead to the 

development of drug-resistant TB 

Treatment of TB Disease (3) 

•	 Intensive phase should

contain the following 

four drugs: 

– Isoniazid (INH) 

– Rifampin (RIF) 

– Pyrazinamide (PZA) 

– Ethambutol (EMB) 

Example of pills used to treat TB disease. From 

left to right: isoniazid, rifampin, pyrazinamide, 

and ethambutol. 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease
 

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68 
Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 73 Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 74 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 75 

INTENSIVE PHASE CONTINUATION PHASE 

Regimen Drugs Interval and Doses 

(minimum 

duration) 

Drugs Interval and 

Doses 

(minimum 

duration) 

Range of 

total 

doses 

Comments Regimen 

effectiveness 

1 INH 

RIF 

PZA 

EMB 

7 days/week for 56 

doses (8 weeks) 

or 

5 days/week for 40 

doses (8 weeks) 

INH 

RIF 

7 days/week for 

126 doses (18 

weeks) 

or 

5 days/week for 90 

doses (18 weeks) 

182 to 130 This is the preferred 

regimen for patients with 

newly diagnosed 

pulmonary TB. 

greater 

lesser 

2 INH 

RIF 

PZA 

EMB 

7 days/week for 56 

doses (8 weeks) 

or 

5 days/week for 40 

doses (8 weeks) 

INH 

RIF 

3 times weekly for 

54 doses (18 

weeks) 

110 to 94 Preferred alternative 

regimen in situations in 

which more frequent DOT 

during continuation phase 

is difficult to achieve. 

3 INH 

RIF 

PZA 

EMB 

3 times weekly for 

24 doses (8 weeks) 

INH 

RIF 

3 times weekly for 

54 doses (18 

weeks) 

78 Use regimen with caution 

in patients with HIV and/or 

cavitary disease. Missed 

doses can lead to 

treatment failure, relapse, 

and acquired drug 

resistance. 

4 INH 

RIF 

PZA 

EMB 

7 days/week for 14 

doses then twice 

weekly for 12 doses 

INH 

RIF 

Twice weekly for 

36 doses (18 

weeks) 

62 Do not use twice-weekly 

regimens in HIV-infected 

patients or patients with 

smear positive and/or 

cavitary disease. If doses 

are missed then therapy is 

equivalent to once weekly, 

which is inferior. 

*For detailed information, refer to the Module 4 – Treatment of Official American Thoracic Society/Centers for Disease Control and Latent Tuberculosis Infection and Tuberculosis Disease Prevention/Infectious Diseases Society of America Clinical Practice Guidelines: Treatment of Drug-Susceptible Tuberculosis. 77 Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 78 

Treatment of TB Disease
 

Study Question 4.14
 

Preventing Drug Resistance (1) 

•	 Drug resistance can develop when patients are 

prescribed an inappropria te regimen 

– TB disease must be treated with at least 2 

drugs to which bacilli are susceptible 

– Using only one drug can create a population 

of tubercle bacilli resistant to that drug 

– Adding a single drug to fa iling regimen may 

have the same effect as only using one drug 

Preventing Drug Resistance (2) 

•	 Resistance can develop when patients do not 

take drugs as prescribed 

– Patients do not tak e all of their pills 

– Patients do not tak e pills as often as
 

prescribed
 

•	 When this happens, patients may expose the 

bacilli to a single drug 

Preventing Drug Resistance (3) •	 Factors that increase the chance of patient having or 

developing drug-resistant TB: 

– Patient does not take their medicine regularly and
 

completely
 

– Patient comes from an area of the world where drugresistant TB is common 

– Malabsorption of drugs 

– Patient is a contact to someone with drug-resistant TB 

– Failure to improve on drug-susceptible regimen 

– Patient develops TB disease again after having taken TB 

medicine in the past 

Treatment of TB Disease


Treatment Regimens 

TB Treatment Regimens* Table. 4.3 

Why must TB disease be treated for at least 6 

months? 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease
 

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76 
Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 79 

Treatment of TB Disease
 

Study Question 4.15
 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 80 

Treatment of TB Disease


Study Question 4.16
 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 81 

Drug Resistance
 

Study Question 4.17
 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 83 Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 84 

Which 4 drugs are recommended for the 

intensive phase of treatment for TB disea se? 

Why should multiple drugs be used to trea t TB 

disease? 

Treatment of TB Disease


Special Considerations 

Special Considerations (2)
 

People Living with HIV
 

•	 For HIV-infected TB patie nts receiving ART, 

the recommended treatment is a 6-month daily 

regimen consisting of: 

– An intensive phase of INH, RIF, PZA, and 

EMB for 2 months 

– A continuation phase of INH and RIF for 4 months 

Name 2 factors that can lea d to drug 

resistance. 

Special Considerations (1) 

•	 TB medical experts should be consulted for 

complicated and c hallenging TB treatment 

issues 

•	 Consultation can be provided by State TB 

Programs and the CDC-funded TB Regional 

Training and M edical Consultation Centers 

(RTMCCs) 

www.cdc.gov/TB/education/rtmc/default.htm 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease
 

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82 
Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 85 Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 86 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 87 Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 88 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 89 Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 90 

Special Considerations (3)
 

People Living With HIV
 

•	 ART should be initiated during TB tre atment to improve treatment outcomes for TB patients living with HIV 

• ART should ideally be initiated 

– Within 2 weeks of starting TB tre atment for 

patients with CD4 cell counts <50/mm3 

– By 8 to 12 weeks of starting TB tre atment for patients with CD4 cell counts >50/mm3 

•	 For patients with TB meningitis or TB inv olving 

the central nervous system, ART should NOT be initiated during the first 8 weeks of TB trea tment 

Special Considerations (4)
 

People Living With HIV
 

•	 It is important to be aware of the interaction of 

RIF with some ART drugs 

– Rifabutin has fewer drug interaction problems 

and may be used as a substitute for RIF for some patients 

•	 DOT should be provided for all TB patie nts living 

with HIV 

•	 For patients not receiving ART during TB 

treatment, it is recommended to extend 

treatment to 9 months 

Special Considerations (5)
 

Pregnant Women
 

•	 Treatment should begin as soon as TB disease is 

diagnosed 

•	 Regimen should consist of at least INH, RIF, and EMB for 

a minimum of 9 months 

•	 Clinicians should seek expert consultation to evaluate 

the risks and benefits of prescribing pyrazinamide (PZA) 

on a case-by-case basis 

•	 Streptomycin (SM) should NOT be used 

•	 Vitamin B6 supplements are recommended for all 

pregnant women taking INH 

Special Considerations (6)
 

Breastfeeding
 

•	 Women being treated with first-line TB drugs 

should not be discouraged from 

breastfeeding 

– Only a small concentration of the drugs is 

found in brea st milk 

– Not harmful to infant 

Special Considerations (8)
 

Children
 

•	 Children younger than 5 years of age should start TB 

treatment as soon as the diagnosis is suspected 

•	 Children can be treated with INH, RIF, PZA, and EMB for 2 

months, followed by INH and RIF for 4 months 

– Children receiving EMB should be monitored for
 

vision changes
 

•	 A 3 drug regimen (INH, RIF, PZA) can be considered in 

the intensive phase for children who are too young to 

have their vision monitored, are not infected with HIV, 

have no prior TB treatment history, and are not at risk for 

having drug-resistant TB 

Special Considerations (7)
 

Breastfeeding
 

•	 Concentration of drugs in breast milk is not 

considered effective treatment for LTBI or TB 

disease for infant 

•	 Vitamin B6 supplements are recommended 

for all w omen who are taking INH and a re 

breastfeeding 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease
 

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Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 91 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 93 Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 94 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 95 Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 96 

Special Considerations (9)
 

People with Extrapulmonary Disease
 

•	 In general, regimens used for tre ating pulmonary 

TB are also effective for treating extrapulmonary 

TB 

•	 9 to 12 month regimen is recommended for TB of the meninges or central nervous system 

•	 6 to 9 month regimen is recommended for bone and joint TB 

Alternative Treatment Regimens (1) 

Drug-Resistant TB 

•	 Alternative regimens should be used for trea ting 

drug-resistant TB 

•	 Treatment of drug-re sistant TB should alw ays 

be done under the supervision of a medical 

expert 

Alternative Treatment Regimens (2) 

Drug-Resistant TB 

•	 INH-resistant TB can be treated with the
 

following regimen:
 

– RIF, EMB, and PZA for 6 months 

Treatment of TB Disease


Alternative Regimens for Treating


Drug-Resistant TB
 

Alternative Treatment Regimens (3) 

MDR TB 

•	 MDR TB is resistant to INH and RIF, and is more difficult 

to treat than drug-susceptible TB 

•	 Drugs that can be used are less effective and are more 

likely to cause adverse reactions 

•	 Treatment can last 18 to 24 months after culture 

conversion 

•	 As a last resort, some patients undergo surgery to 

remove part of the disease site 

•	 Expert consultation should be sought 

Alternative Treatment Regimens (4)

Extensively Drug-Resistant TB (XDR TB) 

•	 XDR TB is resistant to INH, RIF, plus any 

fluoroquinolone, and at le ast one injectable 

second-line drug (e.g., amikacin, kanamycin, or 

capreomycin) 

•	 XDR TB patie nts have less effective treatment 

options 

•	 XDR TB is very difficult to trea t 

•	 Expert consultation should be sought 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease
 

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92 
Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 97 Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 98 

Special Considerations


Study Question 4.18
 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 99 

Special Considerations


Study Question 4.19
 


 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 101 Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 102 

Alternative Treatment Regimens (5)
 

XDR TB 

•	 Successful outcomes for the patient depend 

greatly on: 

– Extent of drug resistanc e 

– Severity of disease 

– Whether the patient’s immune system is 

compromised 

What treatment regimen should be used for 

HIV-infected TB patients? 

In what situations should treatment for TB disease last 

longer than the usual course of treatment? 

Treatment of TB Disease


Treatment and Monitoring Plan and

Adverse Reactions
 

Treatment and Monitoring Plan 

TB Disease 

•	 Every TB patient s hould have a specific 

treatment and monitoring plan developed in 

collaboration with local health department 

•	 Plan should include: 

– Description of trea tment regimen 

– Methods of: 

• Monitoring for adverse reactions 

• Assessing and ensuring adherence to 

treatment 

• Evaluating treatment response 

Monitoring Adverse Reactions (1) 

TB Disease 

•	 Before starting treatment for TB dise ase, 

patients should have baseline blood and 

vision tests to detect problems that may 

complicate treatment 

– For example, patients who are taking 

ethambutol should have baseline visual 

acuity testing and testing of color 

discrimination 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease
 

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100 
Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 103 Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 104 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 105 

 


Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 

Adverse 

Reaction 

Caused 

by 

Signs and Symptoms Significance 

of Reaction* 

Allergic Any drug • Skin rash May be serious 

or minor 

Eye 

damage 

EMB • 

•	 

Blurred or changed vision 

Changed color vision 

Serious 

Hepatitis PZA 

INH 

RIF 

• 

•	 

•	 

•	 

•	 

•	 

•	 

•	 

•	 

•	 

Abdominal pain 

Abnormal liver function test 

results 

Brown urine, light colored stool 

Fatigue 

Fever for 3 or more days 

Flu-like symptoms 

Lack of appetite 

Nausea 

Vomiting 

Yellowish skin or eyes 

Serious 

Table. 4.4 Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 107 

Adverse Caused by Signs and Symptoms Significance of 

Reaction Reaction* 

Nervous INH •	 Dizziness Serious 

system •	 Tingling or numbness 

damage around the mouth 

Peripheral INH •	 Tingling sensation, Serious 

neuropathy numbness, or pain in 

hands and feet 

Stomach PZA •	 Stomach upset May be serious or 

upset •	 Vomiting minor 

• Lack of appetite 

Gout PZA •	 Abnormal uric acid Serious 

level 

•	 Joint aches 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 108 

Adverse 

Reaction 

Caused 

by 

Signs and Symptoms Significance 

of Reaction* 

Bleeding 

problems 

due to low 

platelets 

Discoloration 

of body 

fluids 

Drug 

interactions 

RIF 

RIF 

RIF 

• 

• 

• 

• 

• 

Easy bruising 

Slow blood clotting 

Orange urine, sweat, or tears 

Permanently stained soft 

contact lenses 

Interferes with many 

medications, such as birth 

control pills or implants, blood 

thinners, some HIV medicines, 

and methadone 

Serious 

Minor 

May be 

serious 

or minor 

Monitoring Adverse Reactions (2)


TB Disease
 

•	 Follow-up tests should be done periodically if: 

– Results of baseline tests indicate
 

abnormalities
 

– Patient has symptoms that may be due to 

adverse reactions 

Monitoring Adverse Reactions (3) 

TB Disease 

•	 Patients should be educated about symptoms 

caused by adverse reactions to drugs 

•	 Patients should be seen by clinician at le ast 

monthly during treatment and evaluated for 

possible adverse reactions 

•	 Public health workers who have regular 

contact with patients should ask about 

adverse reactions to treatment 

Monitoring Adverse Reactions (4)
 

TB Disease
 

•	 If patient has 

symptoms of a serious 

adverse reaction, 

HCWs should: 

– Instruct patient to stop


medication
 

– Report situation to
 

clinician and arrange for

medical evaluation
 

– Note symptoms on the
 

patient’s form
 

Adverse Reactions to TB Drugs (1)


Table. 4.4 

Adverse Reactions to TB Drugs (2)
 Adverse Reactions to TB Drugs (3) 

Table. 4.4 

* Patients should stop medication for serious adverse reactions and consult a clinician 

immediately. Patients can continue taking medication if they have minor adverse reactions. 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease


18


106 
Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 109 

TB Treatment and Monitoring Plan

Study Question 4.20 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 110 

Adverse Reactions to TB Drugs

Study Question 4.21
 


 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 111 

TB Treatment Monitoring

Study Question 4.22 


 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 113 Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 114 

What should be included in e ach patient’s
 treatment plan?
 

Treatment of TB Disease


Adherence and Evaluating Patients’

Response to Treatment
 

Adherence to TB Treatment (1)
 

•	 Most effective strategy 

to encourage adherence 

to treatment is DOT 

– Should be considered 

for ALL patients 

– Should be used for all 

children and 

adolescents 

– Should be done at a 

time and place that is 

convenient for patients 

Adherence to TB Treatment (2) 

•	 Incentives and enablers can be used to 

improve patient adherence 

– Incentives are rewards given to patient, 

e.g., gift ca rds 

– Enablers help patient re ceive treatment, 

e.g., bus tokens 

Name the drug or drugs that may cause each of the following symptoms or adverse reaction. 

• Nervous system damage: 

• Hepatitis: 

• Eye damage: 

• Orange discoloration of the urine: 

How often should pa tients be monitored for 

adverse reactions to TB drugs? 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease


19


112 
Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 115 Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 116 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 117 Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 118 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 119 Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 120 

Adherence to TB Treatment (3)
 

•	 Patients should be 

educated about TB 

disease and 

treatment 

– Cause of TB, 

transmission, 

diagnosis, and 

treatment plan 

– How and when to 

take medication 

Evaluating Patients’ Response to 

Treatment (3) 

2.	 Conduct bacteriologic examination of sputum 

or other s pecimens 

•	 Specimens should be examined every 

month until culture results have converted 

from positive to negative 

•	 Any patient whose culture results have 

not become negative after 2 months of 

treatment, or whose results become 

positive after being negative, should be reevaluated 

Evaluating Patients’ Response to
 

Treatment (4)
 

3.	 Use chest x-rays to monitor patient’s response 

to treatment 

•	 Repeated x-rays are not as helpful as 

monthly bacteriologic and clinical 

evaluations 

•	 Chest x-rays taken at end of treatment can 

be compared to any follow-up x-rays 

Monitoring Patients’ Adherence to 

Therapy 

•	 Patients not receiving DOT should be monitored 

for adherence to treatment: 

– Check if patient is reporting to clinic as
 

scheduled
 

– Ask about adherence 

– Ask patient to bring medications to clinic and 

count number of pills taken 

– Use urine tests to detect medication in urine 

– Assess patient’s clinical response to treatment 

Evaluating Patients’ Response to 

Treatment (1) 

Three methods to determine whether a patient 

is responding to tre atment: 

1.	 Check to see if patient ha s TB symptoms
 

(clinical evaluation)
 

2.	 Conduct bacteriologic examination of
 

sputum or other spec imens
 

3.	 Use chest x-rays to monitor patient’s
 

response to treatment
 

Evaluating Patients’ Response to 

Treatment (2) 

1.	 Check to see if patient ha s TB symptoms 

(clinical evaluation) 

•	 TB symptoms should gradually 

improve and go aw ay after starting 

treatment 

•	 Patients whose symptoms do not improve during the first 2 months of 

treatment, or whose symptoms worsen 

after initial improvement, should be reevaluated 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease
 

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Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 121 Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 122 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 123 Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 124 

Adherence to Therapy

Study Question 4.23
 


 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 125 

Adherence to Therapy
 

Study Question 4.24
 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 126 

Response to Treatment 

Study Question 4.25 

Evaluating Patients’ Response to 

Treatment (5) 

•	 TST or IGRA cannot be used to de termine 

whether the patient is responding to 

treatment 

•	 Treatment completion is defined by number 

of doses the patient takes within a specific 

time frame 

•	 Length of tre atment depends on drugs used, 

drug susceptibility test results, and the 

patient’s response to therapy 

Reevaluating Patients Who Do


Not Respond to Treatment (1)
 

•	 Reevaluating the patient means 

– Obtaining a new specimen for TB c ulture, and 

(if positive) drug susceptibility testing 

– Assessing whether the patient has taken
 

medication as prescribed
 

– Reviewing symptoms 

– Performing a clinical examination 

– Repeating chest x-rays 

Reevaluating Patients Who Do Not 

Respond to Treatment (2) 

•	 Patients should be reevaluated if: 

– Symptoms do not improv e in first 2 months 

of therapy 

– Symptoms worsen after improving initially 

– Culture results have not become negative 

after 2 months of treatment 

– Culture results become positive after being 

negative 

– Chest x-rays show worsening 

Name 4 ways clinicians can assess whether 

a patient is adhering to treatme nt. 

What is the best way to ensure that a patient 

adheres to treatment? 

How can clinicians determine whether a 

patient is responding to trea tment? 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease
 

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Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 127 

Reevaluating the Patient

Study Question 4.26 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 128 

Reevaluating the Patient 

Study Question 4.27 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 130 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 131 Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 132 

Role of Public Health Workers 

Study Question 4.28 

Under what circumstances should patients be 

reevaluated? What does reevaluating the patient mean? 

Role of Public Health Workers (1) 

•	 Successful TB treatment is the responsibility 

of medical providers and HCWs, not the patient 

•	 Case management can be used to e nsure that 

patients complete TB treatment 

•	 A health department employee is assigned 

responsibility for the management of specific 

patients 

Treatment of TB Disease


Role of Public Health Workers 

129 

Role of Public Health Workers (2) 

•	 Provide DOT 

•	 Help monitor pa tients’ response to treatment 

•	 Educate patients and families about TB 

•	 Locate patients who have missed DOT v isits or 

clinic appointments 

•	 Act as interpreters, arrange and provide 

transportation for pa tients, and refer patients to 

other social services 

•	 Work with private physicians to make sure TB 

patients complete an adequate regimen 

What is the goal of case management? 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease


22

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 133

Role of Public Health Workers

Study Question 4.29 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 135 

Module 4: Case Study 4.1 (1) 

You are sent to v isit the home of a TB patient

who was admitted to the hospital last week 

and diagnosed w ith infectious TB disease. 

Living in the home are his wife and his 1­

year-old daughter. Neither one has 

symptoms of TB dise ase. You give them both

a TST and return 2 days later to read the 

results. You find tha t the wife has 14 mm of 

induration, but the daughter has no 

induration. 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 136 

Should either one receive further evaluation 

for LTBI or TB dis ease? 

Module 4: Case Study 4.1 (2) 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 137 

Should either one start LTBI tre atment? Explain. 

Module 4: Case Study 4.1 (3) 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 138 

Module 4: Case Study 4.1 (4)

Should either one start LTBI tre atment? Explain. 

(cont.) 

What should a public health worker do if he 

or she notices that a patient has symptoms 

of a serious adverse reaction? Case Studies
 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease


23
 

134 
Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 139 

Module 4: Case Study 4.2 (1)

A 65-year-old man is prescribed LTBI 

treatment with INH because he is a contact of

a person with infectious TB disease and he 

has an induration of 20 mm to the TST. His 

baseline liver function tests are normal, but 

he drinks a six-pack of beer every day. 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 140 

What kind of monitoring is necessary for this patient while he is taking INH? 

Module 4: Case Study 4.2 (2)

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 141 

Module 4: Case Study 4.3 (1)

An 18-month-old girl is admitted to the hospital 

because of meningitis. Doctors discover that 

her grandmother had pulmonary TB disease 

and was treated with a 6-month regimen. The 

medical evaluation of the child confirms the 

diagnosis of TB me ningitis. 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 142 

Module 4: Case Study 4.3 (2) 

How long s hould the child be treated? 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 143 

Module 4: Case Study 4.4 (1) 

You are assigned to deliv er medications to TB 

patients as part of the DOT program where you 

work. When you visit Mr. Jackson’s house, you 

ask him how he is feeling. He tells you that he 

was up all night v omiting. 

Module 4: Case Study 4.4 (2) 

What are the possible causes? What should 

you do? 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 144 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease


24
 
Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 145 

Module 4: Case Study 4.5 (1) 

Ms. Young, a patient who started treatment for 

TB disease last week, calls the TB clinic to 

complain that her urine has changed to an odd 

color. 

Module 4: Case Study 4.5 (2) 

Name 2 possible causes, and explain how each 

would affect the color of urine. 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 146 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 147

Module 4: Case Study 4.6 (1) 

Mr. Vigo was diagnosed with smear-positive 

pulmonary TB disease in January. He was 

treated with INH, RIF, and PZA by his private 

physician. He visited his physician again in 

March. His drug susceptibility test results were

not available at the time of this appointment. 

Nevertheless, the physician discontinued his 

prescription of PZA a nd gave him refills of INH 

and RIF. Mr. Vigo visited his physician again in 

April. He had a persistent cough, a nd his 

sputum smear was found to be positive. 

Module 4: Case Study 4.6 (2) 

What should be done next? 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 148

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 149 

Module 4: Case Study 4.7 (1) 

Ms. DeVonne began treatment for pulmonary 

TB disease 2 months ago, at the beginning of 

September. You have been supervising her 

DOT. During the first few weeks of therapy, 

you noticed that Ms. DeVonne’s symptoms 

were improving a little. However, at a visit in 

October, you see that Ms. DeVonne is 

coughing up blood, a nd she tells you that she 

feels like she has a fever. 

Module 4: Case Study 4.7 (2)

What should you do? 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease 150 

Module 4 – Treatment of Latent Tuberculosis Infection and Tuberculosis Disease
 

25