TB Manual

Diagnosis

• Samples (fluid and tissue) for extra-pulmonary tuberculosis (TB) should be sent for acid-fast bacilli smear, mycobacterial culture and nucleic acid amplification test. Tissue biopsy should be sent in sterile saline for these mycobacterial tests as well as in formalin for histopathologic assessment. Drug susceptibility testing should be requested for positive culture samples.

• If the specimen is insufficient for all testing, mycobacterial culture should be prioritized given it has the highest diagnostic yield and allows for gold-standard phenotypic drug testing.

• Every person with presumed extra-pulmonary TB should also be assessed for pulmonary TB to assess infectiousness and potentially assist with diagnosis.

Treatment

• A standard 6-month anti-TB treatment course for microbiologically confirmed, drug-susceptible disease is recommended for most forms of extra-pulmonary TB. In patients with meningitis or bone and joint TB, treatment may be extended to 12 months.

• In the absence of culture confirmation and drug susceptibility results, the continuation phase of empiric anti-TB treatment should include a third agent such as ethambutol.

• Empiric anti-TB therapy should be considered in suspected life-threatening extra-pulmonary TB while appropriate diagnostic samples are being obtained.

NEW AND UPDATED RECOMMENDATIONS

1. We conditionally recommend against routine adjunctive corticosteroid use for pleural TB.

2. We conditionally recommend against routine therapeutic thoracentesis/chest tube drainage for pleural TB-associated effusions.

3. We conditionally recommend using higher doses of rifampin (greater than 15 mg/kg/day orally up to maximum dose 35 mg/kg/day or 15 mg/kg/day intravenously [IV]) along with standard dose isoniazid, pyrazinamide, and ethambutol, during intensive phase of treatment for drug susceptible TB meningitis (TBM).

4. We conditionally recommend against using fluoroquinolone for TBM unless there is a concern regarding drug resistance.

5. We conditionally recommend initial adjunctive corticosteroid treatment in all human immunodeficiency virus (HIV)-negative patients with TB pericarditis. Routine use of adjunctive corticosteroids in people with HIV NOT on antiretroviral treatment is NOT recommended. Lack of data means we are unable to provide a specific recommendation on use of adjunctive corticosteroids in people with HIV ON antiretroviral treatment with TB pericarditis and suggest assessing on a case-by-case basis pending further study.

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