TB-Related
MMWRs
Background: Severe and Fatal Liver Injury Connected to Latent
TB Treatment
Guidelines for the Treatment Of Latent TB Infection Revised
The Centers for Disease Control and Prevention has investigated
reports of 21 patients who were hospitalized because of severe liver
injury associated with a two-month treatment regimen of rifampin
and pyrazinamide (RIF-PZA) for latent TB infection (LTBI). Sixteen
of the patients recovered and five died. Findings from the investigations
into these cases are included in the August
31 edition of CDC's Morbidity and Mortality Weekly Report
(MMWR).
CDC previously published findings from an investigation into two
cases of severe liver damage associated with RIF-PZA. Only one of
the patients recovered. These cases were outlined in the
April 20 edition of the MMWR, at which time CDC requested
reports of additional cases.
CDC and ATS Revise Guidelines for Latent TB Treatment
As a result of these investigations, CDC and the American Thoracic
Society are issuing revised treatment guidelines for LTBI to limit
the circumstances in which the combination of RIF-PZA is prescribed
and to strengthen the level of patient counseling and monitoring
recommended for LTBI treatment regimens.
For most individuals with LTBI, the new guidelines recommend the
nine-month regimen of daily INH as the preferred treatment. CDC
recommends providers use RIF-PZA with caution, especially in those
currently taking other medications that have been associated with
liver injury, and those with alcoholism even if alcohol usage is
discontinued during treatment.
However, with careful clinical and laboratory monitoring as outlined
in the recommendations, RIF-PZA remains an option for patients at
high risk of developing active TB disease and who are unlikely to
complete a nine-month regimen of isoniazid (INH). For HIV-negative
individuals with LTBI, the new guidelines recommend the nine-month
regimen of daily INH as the standard treatment.
While available data do not suggest excessive risk of severe side
effects associated with RIF-PZA among HIV-positive individuals,
providers should consider the use of INH when completion of this
longer regimen can be assured. Patients co-infected with HIV and
LTBI are at increased risk for developing active TB disease.
Guidelines Emphasize TB Testing and Treatment for People at
High Risk
The goal of testing people for TB is to find and treat those who
have LTBI and are at high risk of developing active TB disease.
Those at high risk include individuals with LTBI who are HIV-infected,
were recent contacts of someone with active TB, injection drug users,
and residents or employees of high-risk congregate settings, which
include correctional facilities, nursing homes, homeless shelters,
hospitals, and other health care facilities. Furthermore, providers
are reminded that treatment is recommended for foreign-born people
with LTBI who have lived in the United States for less than five
years and who were born in countries with high rates of TB. After
five years, treatment decisions should be made on the same basis
as other patients.
Because all regimens for treating LTBI have been associated with
liver injury, careful monitoring during treatment is important to
avoid severe damage. Any additional cases of severe liver damage
associated with treatment of LTBI should be reported to the CDC's
Division of TB Elimination. These recommendations should not affect
patients receiving treatment for active TB.
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Related MMWRs
For information about the previous MMWR on severe liver
damage associated with RIF-PZA:
Fatal and Severe Hepatitis Associated With Rifampin and Pyrazinamide
for the Treatment of Latent Tuberculosis Infection – New York and
Georgia, 2000
The findings from the April 20 MMWR article – Fatal and Severe
Hepatitis Associated With Rifampin and Pyrazinamide for the Treatment
of Latent Tuberculosis Infection --- New York and Georgia, 2000
– underscored the need for clinical monitoring for adverse effects
in all patients receiving treatment for LTBI to help prevent severe
liver damage as a result of LTBI treatment. For a copy of the
April 20 MMWR: www.cdc.gov/mmwr/preview/mmwrhtml/mm5015a3.htm
For information about the original recommendations:
Targeted Tuberculin Testing and Treatment of Latent Tuberculosis
Infection
The recommendation on the treatment on LTBI was included in the
Targeted Tuberculin Testing and Treatment of Latent Tuberculosis
Infection statement developed by a panel of 47 experts from
three continents. American Thoracic Society (ATS) and CDC convened
the panel. The Infectious Diseases Society of America also endorsed
the panel's statement. The American Academy of Pediatrics endorsed
sections of the statement relating to infants and children. It was
published as a supplement to the April 2000 issue of the ATS's
American Journal of Respiratory and Critical Care Medicine,
and was reprinted in CDC's Morbidity and Mortality Weekly Report on June 9, 2000. For a copy of the
June 20, 2000 MMWR: www.cdc.gov/mmwr/preview/mmwrhtml/rr4906a1.htm
Contact:
NCHSTP Office of Communications (404) 639-8895
American Thoracic Society (212) 315-6442 Last Reviewed: 05/18/2008 Content Source: Division of Tuberculosis Elimination
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
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