NICE Guidelines on Drug-resistant TB

National Institute for health and care excellence has released guidelines for Drug-resistant TB. It is an update on the guidelines published in January 2016. The evidence-based recommendations have been developed for all the stakeholders.

Major Recommendations are-

Drug-resistant TB

Multidrug‑resistant TB

1. For people with clinically suspected TB, a TB specialist should request rapid diagnostic nucleic acid amplification tests for rifampicin resistance on primary specimens if a risk assessment for multidrug resistance identifies any of the following risk factors:

• history of previous TB drug treatment, particularly if there was known to be poor adherence to that treatment
• contact with a known case of multidrug-resistant TB
• birth or residence in a country in which the World Health Organization reports that a high proportion (5% or more) of new TB cases are multidrug‑resistant. Start infection control measures. [new 2016]

2. If the rapid diagnostic nucleic acid amplification test for rifampicin resistance is positive:

• continue infection control measures until the pulmonary or laryngeal disease has been excluded
• manage treatment along with a multidisciplinary team with experience of managing multidrug‑resistant TB
• offer a treatment regimen involving at least 6 drugs to which the mycobacterium is likely to be sensitive
• test for resistance to second‑line drugs. [new 2016]

3. If the rapid diagnostic nucleic acid amplification test for the M. tuberculosis complex is positive but rifampicin resistance is not detected, treat as drug‑susceptible TB with the standard regimen. [new 2016]

4. If the rapid diagnostic nucleic acid amplification test for the M. tuberculosis complex is negative in a person at high risk of multidrug‑resistant TB:

• obtain further specimens for nucleic acid amplification testing and culture, if possible
• use rapid rifampicin resistance detection on cultures that become positive for the M. tuberculosis complex
• consider waiting for the results of further tests before starting treatment if the person is well
• if urgent treatment is needed, consider managing as multidrug‑resistant TB until sensitivity results are available. [new 2016]

5. When definitive phenotypic susceptibility results are available, modify treatment as needed. [new 2016]

6. Consider more intensive clinical follow‑up for people with multidrug‑resistant TB. This includes people having directly observed therapy throughout treatment because of the complexity of treatment and risk of adverse events. [new 2016]

7. Discuss the options for organising care for people with multidrug‑resistant TB with clinicians who specialise in this. Seek the person's views and take them into account, and consider shared care. [2006]

8. Consider surgery as a therapeutic intervention in people with potentially resectable multidrug‑resistant disease if:

• optimal medical therapy under direct observation has not worked or
• medical therapy is likely to fail because of extensively drug-resistant TB. [new 2016]

Drug‑resistant TB (excluding multidrug‑ and extensively drug‑resistant TB)

1. For people with TB, without central nervous system involvement, that is resistant to just 1 drug consider the treatments in table 13.

Table- Treatment regimen for people with TB that is resistant to 1 drug

2. For people with drug‑resistant TB and central nervous system involvement, involve a TB specialist with experience in managing drug‑resistant TB in decisions about the most appropriate regimen and the duration of treatment. [new 2016]

D. Infection control

1. Healthcare settings

1. Ensure healthcare settings can promptly identify people with suspected infectious or confirmed pulmonary or laryngeal TB before or at presentation. Ensure people working in the settings follow the recommendations about testing and treatments. [new 2016]

2. Put people with suspected infectious or confirmed pulmonary or laryngeal TB who will remain in a hospital setting (including emergency, outpatients or inpatient care) in a single room. If this is not possible, keep the person's waiting times to a minimum. This may involve prioritising their care above that of other patients. [new 2016]

3. Minimise the number and duration of visits a person with TB makes to an outpatient department while they are still infectious. To minimise the risk of infection, people with infectious TB should be seen at times or in places away from other people. [new 2016]

4. In hospital settings, risk assess people with suspected infectious or confirmed pulmonary TB for multidrug‑resistant TB. Care for people deemed to be at low risk in a single room, as a minimum. For people deemed to be at high risk:

• provide care in a negative pressure room and
• have specimens sent for rapid diagnostic tests, such as nucleic acid amplification tests. [new 2016]

5. Unless there is a clear clinical or public health need, such as homelessness, people with suspected infectious or confirmed pulmonary TB should not be admitted to the hospital for diagnostic tests or for care. [2006, amended 2016]

6. Do not admit people with suspected infectious or confirmed pulmonary TB to a ward containing people who are immunocompromised, such as transplant recipients, people with HIV and those on anti-tumor necrosis factor-alpha or other biologics, unless they can be cared for in a negative pressure room on the same ward. [new 2016]

7. Assess any visitors to a child with suspected active TB in the hospital for symptoms of infectious TB, and keep them separate from other people until they have been excluded as a source of infection. [new 2016]

8. Care for people with a continuing clinical or public health need for admission with pulmonary TB in a single room (as a minimum) until they have completed 2 weeks of the standard treatment regimen if they:

• are unlikely to be rifampicin-resistant (that is, do not have risk factors for multidrug‑resistant TB) or
• have negative rifampicin resistance on nucleic acid amplification test or culture. [new 2016]

9. Consider de‑escalating isolation after 2 weeks of treatment, taking into account the risks and benefits, if:

• the person is showing tolerance to the prescribed treatment
• there is agreement to adhere to treatment
• there is resolution of cough
• there is definite clinical improvement on treatment; for example, remaining afebrile for a week
• there are not immunocompromised people, such as transplant recipients, people with HIV and those on anti‑tumour necrosis factor-alpha or other biologics, in the same accommodation
• the person's initial smear grade was not high; for example, 2 or less
• there is not extensive pulmonary involvement, including cavitation
• there is no laryngeal TB. [new 2016]

10. In people who may have TB, only carry out aerosol‑generating procedures such as bronchoscopy, sputum induction or nebulizer treatment in an appropriately engineered and ventilated area (ideally a negative pressure room). [new 2016]

11. Consider discharging from hospital people:

• who do not have a continuing clinical or public health need for admission with pulmonary TB and
• who are unlikely to be rifampicin-resistant (that is, do not have risk factors for multidrug‑resistant TB) or
• who have negative rifampicin resistance on nucleic acid amplification test or culture.If discharged, the person should avoid congregate settings for the first 2 weeks of their treatment. [new 2016]

12.Explain to inpatients with suspected infectious or confirmed pulmonary or laryngeal TB that they will need to wear a surgical mask in the hospital whenever they leave their room. Ask them to continue wearing it until they have had at least 2 weeks of treatment. [2016]

13. Offer people advice on simple respiratory hygiene measures. [new 2016]

Non‑healthcare settings

1. In non‑healthcare settings catering for large numbers of people and populations at high risk of TB (such as detention settings, residential hostels and day centres):

• promote simple respiratory hygiene
• ensure awareness of symptoms of potentially infectious TB to enable prompt healthcare referral
• work with the local public health team and the local authority to ensure accommodation for people with TB
• ensure adequate ventilation. [new 2016]

2. In prisons or immigration removal centres, everyone with X‑ray changes indicative of active TB, as well as those with symptoms who are awaiting X‑ray, should be isolated in an adequately ventilated individual room or cell. Prisoners and detainees should be retained on medical hold until they have:

• proven smear‑negative and had an X‑ray that does not suggest active TB or
• had a negative risk assessment for multidrug‑resistant TB and completed 2 weeks of the standard treatment regimen. [2012, amended 2016]

Multidrug‑resistant TB

1. If people with suspected or known infectious multidrug‑resistant TB are admitted to hospital, admit them to a negative pressure room. If none is available locally, transfer them to a hospital that has these facilities and a clinician experienced in managing complex drug‑resistant cases. Carry out care in a negative pressure room for people with:

• suspected multidrug‑resistant TB, until non‑resistance is confirmed
• confirmed multidrug‑resistant TB, until they have 3 negative smears at weekly intervals and ideally have a negative culture. [new 2016]

2. As soon as possible, explore options to reduce the psychosocial impact of prolonged isolation. For example, through providing free access to internet, telephone and television, and accompanied walks in the open air. [new 2016]

3. Consider earlier discharge for people with confirmed multidrug‑resistant TB, if there are suitable facilities for home isolation and the person will adhere to the care plan. [new 2016]

4. For people with confirmed multidrug‑resistant TB whose symptoms have improved and who are unable to produce sputum, discharge decisions should be taken by the multidisciplinary team and the health protection team. [new 2016]

5. Staff and visitors should wear filtering facepiece (FFP3) masks during contact with a person with suspected or known multidrug‑resistant TB while the person is thought to be infectious. [2016]

6. Before deciding to discharge a person with suspected or known multidrug‑resistant TB from the hospital, agree with the person and their carers secure arrangements for supervising and administering all anti‑TB therapy. [2016]

7. Discuss the decision to discharge a person with suspected or known multidrug‑resistant TB with:

• the infection control team and
• the local microbiologist and
• the local TB service and
• the health protection team. [2016]

8. Ensure negative pressure rooms used for infection control in multidrug‑resistant TB meet the standards of the Interdepartmental Working Group on Tuberculosis, and are clearly identified for staff, for example by a standard sign. Keep such signs up to date. [2016]

For further reference log on to www.nice.org.uk