Mycobacterium Tuberculosis Infection and Disease Flashcards
(200 cards)
1
Q
What is the leading cause of morbidity and mortality among people with HIV worldwide?
A
Tuberculosis (TB)
2
Q
How many estimated TB deaths occurred in 2020 and 2021?
A
1.5 million in 2020 and 1.6 million in 2021
3
Q
What percentage of people with HIV who had TB were diagnosed and reported?
A
52%
4
Q
What was the number of deaths attributed to TB among people with HIV in 2021?
A
187,000 deaths
5
Q
What is the percentage of TB deaths among people with HIV compared to TB cases?
A
11.8% of deaths vs. 6.7% of TB cases
6
Q
What has been the trend in HIV-associated TB deaths since 2006?
A
First increase in TB deaths since 2006
7
Q
What proportion of newly reported TB cases in the U.S. in 2021 were born outside the United States?
A
71.4%
8
Q
What was the percentage of reported TB cases with known HIV status that were coinfected with HIV in 2021?
A
4.2%
9
Q
What is latent TB infection (LTBI)?
A
A condition where viable Mycobacterium tuberculosis can persist for years without causing symptoms
10
Q
What is the risk of TB disease due to reactivation of LTBI for untreated HIV patients?
A
3% to 16% per year
11
Q
What is the risk of TB disease among people with untreated HIV compared to those without HIV?
A
3 to 12 times greater
12
Q
What is the most common predisposing factor for TB infection in the U.S.?
A
Birth or residence outside of the United States
13
Q
What therapy significantly reduces the risk of TB disease in people with HIV?
A
ART and treatment of LTBI
14
Q
What percentage reduction in TB disease risk was observed with isoniazid preventive therapy combined with ART?
A
76%
15
Q
What should all people with HIV be evaluated for at the time of diagnosis?
A
LTBI
16
Q
What are the two current diagnostics available for detecting M. tuberculosis infection in the U.S.?
A
IGRA and TST
17
Q
What is the limitation of TST in diagnosing LTBI?
A
Decreased specificity and sensitivity
18
Q
What are IGRAs used for?
A
Detecting LTBI and differentiating those with and without TB infection
19
Q
What does a positive TST test indicate?
A
Possible LTBI, but does not alone warrant therapy
20
Q
What is the recommended therapy for LTBI in people with HIV?
A
Isoniazid plus rifapentine for 12 weeks or isoniazid plus rifampin for 3 months
21
Q
What is the maximum dose of rifapentine for someone weighing over 50 kg?
A
900 mg
22
Q
What is the alternative therapy for LTBI treatment?
A
Isoniazid for 6-9 months or Rifampin for 4 months
23
Q
What is the recommendation regarding ART for people with LTBI?
A
Deferring ART until after LTBI treatment is not recommended
24
Q
What are the pregnancy considerations for treating LTBI?
A
4R and 3HR are acceptable; therapy may be deferred until after delivery
25
What is the gold standard for diagnosing pulmonary TB disease?
Obtaining a sputum specimen for M. tuberculosis identification
26
What is the predictive value of a negative symptom screen plus a normal chest radiograph?
Usually sufficient to exclude TB disease
27
What is the significance of a positive TST or IGRA?
All positive results should be evaluated for active TB disease
28
What is the correlation between TST and IGRA test results in people with HIV?
Poor to moderate correlation
29
What is recommended for people with advanced HIV and negative LTBI tests?
Retesting for LTBI once they start ART and attain a CD4 count ≥200 cells/mm3
30
What is the recommendation for annual testing for LTBI?
Only for those at high risk for ongoing exposure to active TB
31
What is the effect of rifamycins on antiretroviral (ARV) agents?
They have important drug–drug interactions that affect the selection of LTBI regimens.
32
What screening tests are used for LTBI?
Tuberculin skin test (TST) and interferon-gamma release assay (IGRA).
33
What should people with HIV and a positive TB screening test receive?
LTBI treatment unless there is documentation of prior treatment for active TB or LTBI.
34
True or False: People with HIV in close contact with someone with infectious TB should receive LTBI treatment regardless of TB screening results.
True
35
What is the preferred regimen for LTBI treatment in people with HIV?
3HP: Rifapentine once weekly plus isoniazid for 12 weeks.
36
What is the effectiveness of 3HP compared to 6 to 9 months of daily isoniazid?
3HP is as effective and well-tolerated.
37
What is the recommended treatment for LTBI in people with HIV using isoniazid and rifampin?
3HR: Isoniazid daily plus rifampin daily for 3 months.
38
What is the alternative regimen for LTBI treatment when drug interactions limit rifamycin use?
Isoniazid 300 mg daily for 6 to 9 months with pyridoxine.
39
What is the dosage of rifampin in the 4R regimen?
Rifampin 600 mg PO daily for 4 months.
40
What is the recommendation for using 4R in people with HIV?
Recommended only as an alternative due to limited trial data.
41
What is the alternative therapy for LTBI involving isoniazid and rifapentine for 4 weeks?
1HP: Isoniazid plus rifapentine.
42
What should be monitored in individuals receiving LTBI therapy?
Adherence and possible drug toxicity.
43
Fill in the blank: The abbreviation 'LTBI' stands for _______.
latent tuberculosis infection.
44
What is the maximum dose of isoniazid in the 3HP regimen?
15 mg/kg PO once weekly (900 mg maximum).
45
What is the role of pyridoxine in isoniazid treatment?
To prevent peripheral neuropathy.
46
What is the importance of monitoring liver function in people with HIV receiving isoniazid?
People with chronic viral hepatitis have an increased risk of hepatotoxicity.
47
True or False: Treatment completion rates for 3HP are generally high.
True
48
What is the CD4 count threshold mentioned for participants in the 3HP trials?
>350 cells/mm3.
49
What is the recommended action for people exposed to drug-resistant TB?
Select a regimen after consultation with experts.
50
What is the dosing recommendation for isoniazid when used with rifapentine in the 3HP regimen?
15 mg/kg PO once weekly.
51
What is the treatment completion rate for the 1HP regimen in the BRIEF-TB study?
97%.
52
What is the significance of the BRIEF-TB study?
It evaluated 1 month of daily rifapentine plus isoniazid in people with HIV.
53
What should be done before starting LTBI treatment in people with HIV?
Measure serum AST or ALT and total bilirubin levels.
54
What is the alternative regimen for LTBI that involves isoniazid for 6 to 9 months?
Isoniazid 300 mg PO daily.
55
What is the dosing recommendation for rifampin in the 4R regimen?
600 mg PO daily for 4 months.
56
What is the risk associated with rifamycin monotherapy in undiagnosed early-stage TB disease?
Theoretical risk of selecting for drug-resistant TB.
57
Fill in the blank: The abbreviation 'ART' stands for _______.
antiretroviral therapy.
58
What is the primary concern when using rifampin for LTBI treatment?
Need for dose adjustment of commonly used ARVs.
59
What is the recommendation for using dolutegravir with 1HP?
Await results from a trial before co-administration.
60
What should be measured before starting LTBI treatment in people with HIV?
Serum aspartate aminotransferase (AST), alanine aminotransferase (ALT), and total bilirubin levels
## Footnote
These levels should be repeated if abnormal.
61
What increases the risk of isoniazid-related hepatotoxicity?
Factors include:
* Daily alcohol consumption
* Underlying liver disease
* Pregnancy and early postpartum
* Concurrent treatment with other hepatotoxic drugs
## Footnote
Monitoring is essential for individuals with these risk factors.
62
When should LTBI treatment be stopped based on ALT or AST levels?
If:
1. ALT or AST > five times the upper limit of normal without symptoms
2. ALT or AST > three times the upper limit of normal AND total bilirubin > two times the upper limit of normal without symptoms
3. ALT or AST > three times the upper limit of normal with symptoms
## Footnote
Or greater than two times the baseline value for patients with baseline abnormal transaminases.
63
What influences the presentation of TB disease in people with HIV?
The degree of immunodeficiency
## Footnote
For example, CD4 counts <200 cells/mm3 show markedly different chest radiographic findings.
64
What are common chest radiographic manifestations of TB among most people?
Upper lobe infiltrates with or without cavitation
## Footnote
This is true for both people with and without HIV.
65
What is the recommended initial diagnostic testing for suspected TB disease?
Chest imaging and sputum acid-fast bacilli (AFB) smear, nucleic acid amplification (NAA) testing, and AFB culture
## Footnote
This is essential even in the absence of pulmonary symptoms.
66
True or False: Sputum culture yield is affected by HIV status.
False
## Footnote
Sputum culture yield remains consistent regardless of HIV or the degree of immunodeficiency.
67
What is the sensitivity of NAA tests compared to AFB smears?
NAA tests are more sensitive, positive in 50% to 80% of smear-negative, culture-positive sputum specimens
## Footnote
Sensitivity increases up to 90% when three NAA tests are performed.
68
What is Lipoarabinomannan (LAM)?
A cell wall polysaccharide of M. tuberculosis detectable in the urine of people with TB
## Footnote
LAM has increased sensitivity as an adjunct diagnostic test in people with HIV.
69
What criteria should prompt evaluation for TB drug resistance in people with HIV?
Criteria include:
* Known exposure to drug-resistant TB
* Residence in a high drug-resistant TB setting
* Persistently positive smear or culture after 4 months of treatment
* Previous TB treatment
## Footnote
Each of these scenarios increases the likelihood of drug resistance.
70
What is the definition of multidrug-resistant TB (MDR TB)?
Resistance to at least isoniazid and rifampin
## Footnote
Extensively drug-resistant TB (XDR TB) includes additional resistance to a fluoroquinolone and either bedaquiline or linezolid.
71
What is the main disadvantage of conventional growth-based drug-susceptibility testing?
Turnaround time can be as long as 8 weeks due to slow growth of M. tuberculosis
## Footnote
This delay can lead to ineffective treatment and further complications.
72
What is the Xpert MTB/RIF assay used for?
To detect M. tuberculosis and mutations in the rpoB gene associated with rifampin resistance
## Footnote
It is widely implemented in resource-limited settings.
73
What is the sensitivity of the Xpert MTB/RIF assay in smear-positive specimens?
Up to 95%
## Footnote
Sensitivity in smear-negative specimens is lower, around 69%.
74
What does the Alere Determine TB LAM test detect?
LAM in urine samples from people with TB
## Footnote
It is recommended by WHO as an additional diagnostic test for TB among people with HIV.
75
What is the role of molecular tests in TB drug resistance?
To identify mutations that confer drug resistance for rapid detection
## Footnote
These tests are essential for timely adjustment of treatment regimens.
76
What do commercially available line probe assays (LPAs) identify?
Genotypic resistance to drugs, including rifampin
## Footnote
LPAs are tools used to detect resistance mutations in TB.
77
What should all probe-based assays be confirmed with?
Sequence-based tests and growth-based DST
## Footnote
DST stands for Drug Susceptibility Testing.
78
What service does the CDC Division of Tuberculosis Elimination offer?
Molecular Detection of Drug Resistance (MDDR) service for rapid sequencing-based testing
## Footnote
This service is provided at no charge for providers evaluating patients for drug-resistant TB.
79
What is the positive predictive value for NAA tests of rifampin resistance in low TB prevalence settings?
Low
## Footnote
NAA stands for Nucleic Acid Amplification.
80
What is recommended for patients requiring treatment for HIV-related TB?
Directly Observed Therapy (DOT)
## Footnote
DOT ensures adherence to the treatment regimen.
81
What is the preferred therapy for the intensive phase of drug-susceptible TB?
Isoniazid plus (rifampin or rifabutin) plus pyrazinamide plus ethambutol plus pyridoxine 25–50 mg PO daily
## Footnote
AI denotes a strong recommendation based on high-quality evidence.
82
What is the total duration of therapy for pulmonary, drug-susceptible, uncomplicated TB?
6 months
## Footnote
Duration may vary based on the severity of the disease.
83
What is the recommended initial treatment regimen for pregnant people with TB?
The same as for nonpregnant people, with specific considerations
## Footnote
Monthly monitoring of liver transaminases is recommended during pregnancy.
84
What is the intensive phase treatment for drug-resistant TB?
Isoniazid plus pyrazinamide plus ethambutol plus (moxifloxacin or levofloxacin) plus (linezolid or amikacin)
## Footnote
BII denotes a moderate recommendation based on moderate-quality evidence.
85
What should be monitored monthly during pregnancy for TB therapy?
Liver transaminases
## Footnote
Monitoring is crucial to prevent liver complications.
86
What is the dosing recommendation for isoniazid in TB treatment?
5 mg/kg (usual dose 300 mg)
## Footnote
Isoniazid should be used with pyridoxine to prevent neuropathy.
87
What is the duration for managing drug-resistant TB?
6–24 months
## Footnote
Treatment duration is individualized based on clinical response and drug susceptibility.
88
What is the recommendation for corticosteroid use in patients with CNS involvement in TB?
Adjunctive corticosteroid is recommended
## Footnote
Dexamethasone is commonly used in these cases.
89
What is the intensive phase regimen for patients receiving an efavirenz-based ARV regimen?
Isoniazid plus rifapentine 1,200 mg plus moxifloxacin 400 mg plus pyrazinamide plus pyridoxine 25–50 mg PO daily
## Footnote
This regimen is not recommended for extrapulmonary TB.
90
What is the treatment recommendation for paradoxical TB-IRIS?
Prednisone for moderately severe cases
## Footnote
The tapering schedule for prednisone should be based on clinical symptoms.
91
What is the recommendation for fluoroquinolones in pregnant people?
Typically not recommended due to potential arthropathy
## Footnote
However, they can be used if required for drug-resistant TB.
92
What is the recommendation for treating TB disease in patients with advanced immunodeficiency?
Empiric treatment should be initiated after specimen collection
## Footnote
This is crucial to prevent rapid disease progression.
93
What is the recommended dose of rifampin for TB treatment?
10 mg/kg (usual dose 600 mg)
## Footnote
Adjustments may be necessary based on ARV interactions.
94
What is the duration of therapy for extrapulmonary TB with TB meningitis?
9–12 months
## Footnote
This duration reflects the severity of the disease.
95
What is the intensive phase treatment for drug-susceptible TB in terms of drug combination?
Isoniazid, rifampin, ethambutol, and pyrazinamide
## Footnote
Ethambutol can be discontinued if susceptibility is confirmed.
96
What should clinicians do if a patient shows rifampin resistance?
Confirm susceptibility to isoniazid before including it in treatment
## Footnote
Many patients with rifampin resistance also have isoniazid resistance.
97
What is the role of aminoglycosides in TB treatment during pregnancy?
Should be avoided if possible due to risk of ototoxicity
## Footnote
This is based on data from studies on streptomycin and kanamycin.
98
What is the dosing recommendation for pyrazinamide in TB treatment?
Weight-based dosing
## Footnote
Example: 1,000 mg for 40–55 kg, 1,500 mg for 56–75 kg.
99
What is the recommendation for intermittent rifamycin use in TB treatment?
Not recommended due to the risk of developing resistance
## Footnote
Continuous use is crucial for efficacy.
100
What are the first-line drugs for treating tuberculosis (TB)?
isoniazid, rifampin, ethambutol, pyrazinamide
## Footnote
These drugs are categorized as AI.
101
When can ethambutol be discontinued during TB treatment?
When susceptibility to isoniazid and rifampin has been confirmed.
102
What is the recommended continuation phase of therapy for uncomplicated TB?
4 months (18 weeks) of isoniazid and a rifamycin.
103
What is the extended therapy duration recommended for certain TB patients?
9 months for patients with positive sputum culture after 2 months or severe cavitary or disseminated extrapulmonary disease.
104
What was the outcome of the recent clinical trial comparing 4-month and 6-month TB regimens?
The 4-month regimen was non-inferior to the 6-month regimen in both microbiologically eligible and assessable populations.
105
What were the unfavorable outcome rates for the 4-month regimen compared to the control?
15.5% vs. 14.6% and 11.6% vs. 9.6%.
106
What is the recommended alternative TB regimen for people aged 12 years or older?
4-month regimen of rifapentine, moxifloxacin, isoniazid, and pyrazinamide.
107
Who is the 4-month TB regimen not recommended for?
Children under 12, pregnant people, those with extrapulmonary TB, or those on non-efavirenz-based antiretroviral regimens.
108
What should be done if rapid DST results indicate resistance to rifampin?
Use an initial MDR TB regimen.
109
What is Directly Observed Therapy (DOT)?
DOT is monitored by trained health care workers and is recommended for all people with HIV-related TB.
110
What alternatives may enhance DOT for TB treatment?
Digital technology such as video-DOT and pill sensors.
111
What is the recommended dosing frequency during TB treatment?
Daily therapy is recommended during both the intensive and continuation treatment phases.
112
What has been shown regarding intermittent dosing in people with HIV?
Intermittent dosing can increase the risk of treatment failure or relapse with acquired drug resistance.
113
What does the optimal duration of TB treatment for people with HIV remain?
Not fully established.
114
What did earlier recommendations for TB treatment in people without HIV focus on?
The number of doses received rather than the duration of therapy.
115
What were the findings of trials regarding treatment duration for TB in high-burden settings?
Higher risk of recurrent TB among those treated with 6 months compared to 9 or 12 months.
116
What is currently known about the 4-month regimen in people with HIV on efavirenz-based ART?
Not associated with a higher rate of recurrent TB compared to standard care after 18 months.
117
What is the recommended treatment duration for tuberculous meningitis?
9 to 12 months, though evidence for this is sparse.
118
What adjunctive therapy is recommended for TB involving the CNS?
Corticosteroid therapy.
119
What may be beneficial in treating TB meningitis according to recent trials?
Higher rifampin doses or the addition of fluoroquinolones or linezolid.
120
What is the effect of adjunctive corticosteroid therapy on TB meningitis?
Increases survival, improves treatment effectiveness, reduces adverse event rates
## Footnote
Trials excluded people with HIV or were underpowered for that group
121
What was the outcome of a recent clinical trial on adjunctive corticosteroids in people with HIV?
Failed to find a statistically significant benefit on survival
## Footnote
HR for death 0.85 [95% CI, 0.66–1.10]
122
What is the recommended dose of dexamethasone for TB meningitis?
0.3 mg/kg/day to 0.4 mg/kg/day for 2 to 4 weeks, then tapered
## Footnote
Total duration of 12 weeks
123
Is adjunctive corticosteroid therapy recommended for TB pericarditis?
No, it is not recommended
## Footnote
Prednisolone did not show significant benefit in trials
124
What does the American Thoracic Society recommend regarding ART initiation for HIV and TB patients?
ART should not be withheld until completion of TB treatment
## Footnote
Supported by large randomized trials
125
When should ART be started in ART-naive patients with CD4 <50 cells/mm3?
Within 2 weeks after TB treatment initiation
## Footnote
When TB meningitis is not suspected
126
What is the risk of starting ART in patients with TB meningitis?
Occurrence of intracerebral TB-IRIS
## Footnote
Reported in up to 50% of patients
127
What should be done for patients on ART when TB occurs?
Start TB treatment immediately and modify ART
## Footnote
To reduce drug interactions
128
What is the preferred ART regimen for co-treatment of HIV in most ART-naive people with TB?
Dolutegravir with two nucleoside reverse transcriptase inhibitors
## Footnote
Includes TDF, TAF, abacavir, emtricitabine, or lamivudine
129
What is the clinical significance of rifamycin interactions with ARV drugs?
Potent induction of genes involved in metabolism and transport of ARV agents
## Footnote
Should be considered before initiating therapy
130
What is the recommendation for the use of efavirenz with rifampin?
600 mg daily is recommended
## Footnote
No significant effect on plasma concentrations observed
131
Is nevirapine recommended for HIV and TB co-treatment?
No, it is not recommended
## Footnote
Due to adverse interactions
132
What is the recommended dosing for dolutegravir when used with rifampin?
50 mg twice daily
## Footnote
Recommended for two weeks post TB therapy
133
What should be done if a rifamycin cannot be used in TB treatment?
Extend treatment duration and increase complexity
## Footnote
Individuals with rifamycin-susceptible isolates should still be treated with rifamycins unless serious adverse events are likely
134
What is the recommendation for using bictegravir with rifamycin-containing TB treatment?
Should not be used together
## Footnote
Reduces bictegravir concentrations significantly
135
What should be done for patients who require rifabutin instead of rifampin?
Adjust rifabutin dosage appropriately
## Footnote
E.g., increase to 450–600 mg daily when given with efavirenz
136
What is the effect of rifampin on bictegravir concentrations?
Reduces bictegravir trough concentrations by 80% with dose adjustment
## Footnote
This effect was evaluated in healthy participants without HIV.
137
Is elvitegravir/cobicistat recommended with TB treatment containing rifamycins?
No, it is not recommended (AII)
## Footnote
This conclusion is based on studies involving rifabutin.
138
What effect does rifampin have on cabotegravir AUC?
Decreases cabotegravir AUC by 59%
## Footnote
This was observed in healthy volunteers.
139
Can oral cabotegravir be coadministered with rifabutin?
Yes, it may be coadministered with rifabutin (AIII)
## Footnote
However, long-acting injectable cabotegravir plus rilpivirine is not recommended with rifabutin.
140
What is the effect of rifampin on protease inhibitors (PIs)?
Decreases plasma concentrations and exposure by >75%
## Footnote
This significant reduction was observed in trials involving boosted PIs.
141
What should be done if boosted darunavir is used with rifampin?
Not recommended, even with dose adjustment (AI)
## Footnote
A trial was stopped early due to high rates of hepatotoxicity.
142
How can the effects of rifampin on lopinavir/ritonavir PK be overcome?
By doubling the dose of lopinavir/ritonavir
## Footnote
This approach was reasonably well tolerated in studies.
143
What is the recommended dose of rifabutin when coadministered with ritonavir-boosted PIs?
150 mg daily
## Footnote
This is to avoid dose-related toxicity such as uveitis and neutropenia.
144
What is the recommended monitoring frequency for patients on double-dose lopinavir/ritonavir?
More frequently initially, then monthly once transaminase levels are stable
## Footnote
Regular monitoring of transaminases and HIV RNA is recommended.
145
What is the definition of culture conversion for pulmonary TB therapy?
Two consecutive negative cultures
## Footnote
Sputum cultures from patients with susceptible TB typically convert to negative within 2 months.
146
What should be done if sputum cultures do not convert to negative after 4 months of therapy?
Indicate treatment failure and prompt further evaluation
## Footnote
This may include drug-resistance testing of available specimens.
147
What are some causes of treatment failure in TB?
* Undetected primary drug resistance
* Inadequate adherence to therapy
* Incorrect or inadequate prescribed regimen
* Subtherapeutic drug levels
* Reinfection or mixed infection with drug-resistant M. tuberculosis
* Acquired drug resistance
148
What is the recommended action for managing suspected treatment failure?
Evaluate with medical history, physical exam, and chest radiograph
## Footnote
Initial culture results and drug-resistance tests should be reviewed.
149
What should be monitored in patients on ART and anti-TB therapy?
Adverse drug reactions
## Footnote
Retrospective studies show increased risk, but randomized trials indicate no significant additive toxicity.
150
What should be done if anti-TB DILI criteria are fulfilled?
Stop all potentially hepatotoxic drugs
## Footnote
Perform serologic testing for syphilis and hepatitis A, B, and C.
151
What is the definition of anti-TB DILI?
ALT elevation ≥3 times ULN with symptoms or ALT ≥5 times ULN alone
## Footnote
This can occur in approximately 5% to 30% of people treated with the standard four-drug regimen.
152
What should be considered when rechallenging with first-line anti-TB drugs?
Add each drug individually to the bridging regimen at 7-day intervals
## Footnote
Monitoring ALT levels frequently during rechallenge is essential.
153
What is the recommended regimen for people with isoniazid monoresistance?
Substitute a fluoroquinolone for isoniazid with rifampin or rifabutin, pyrazinamide, and ethambutol for 6 months (BII)
## Footnote
This approach is particularly important for people with HIV and TB.
154
What is the preferred therapy for people with HIV and pulmonary RR-TB?
BPaLM regimen
## Footnote
This regimen includes bedaquiline, pretomanid, and linezolid.
155
What should be done if a patient with RR-TB has fluoroquinolone resistance?
Receive BPaL without moxifloxacin (AI)
## Footnote
This recommendation aligns with WHO guidelines.
156
What is the recommended therapy for people with HIV with pulmonary RR-TB without known resistance?
BPaLM
## Footnote
BPaLM is preferred over BPaL as per recent guidelines.
157
What should patients with RR-TB and fluoroquinolone resistance receive?
BPaL without moxifloxacin
## Footnote
This recommendation aligns with WHO guidelines.
158
What is the recommended duration for BPaLM and BPaL regimens?
26 weeks (6 months)
## Footnote
Treatment can be extended to 39 weeks if sputum cultures are positive.
159
For patients not included in BPaL or BPaLM studies, what is recommended?
An individualized regimen of at least 5 active drugs
## Footnote
Based on resistance testing and prior treatment exposure.
160
What component medications should be included in an initial individualized regimen?
* Bedaquiline
* Linezolid
* Fluoroquinolone (levofloxacin or moxifloxacin)
* Clofazimine
* D-alanine analog (cycloserine or terizidone)
## Footnote
Other drugs should be added only if recommended ones cannot be used.
161
What drugs are no longer recommended due to treatment failure risk?
Kanamycin and capreomycin
## Footnote
Amikacin may be used when less toxic drugs cannot be.
162
What is the recommended treatment duration for an individualized regimen after culture conversion?
15 to 24 months
## Footnote
Current guidelines are undergoing revision.
163
What is a significant concern regarding BPaL(M) regimens?
Growing prevalence of bedaquiline resistance
## Footnote
Lack of widespread availability of phenotypic testing is also a concern.
164
What should be performed prior to starting treatment for RR/MDR TB?
Rapid molecular testing with confirmatory sequencing
## Footnote
This includes testing for fluoroquinolones and first-line drugs.
165
What is the consequence of efavirenz when used with bedaquiline?
Decreases bedaquiline plasma concentrations
## Footnote
Efavirenz should not be used with bedaquiline.
166
What is TB-IRIS?
A frequent complication of ART in people with HIV with active TB
## Footnote
It results from the immune system responding to M. tuberculosis antigens.
167
What are the two forms of TB-IRIS?
* Paradoxical TB-IRIS
* Unmasking TB-IRIS
## Footnote
Each has different clinical presentations and implications.
168
What characterizes paradoxical TB-IRIS?
New or recurrent symptoms and worsening clinical features after starting ART
## Footnote
Occurs typically within 1 to 4 weeks of starting ART.
169
What is the pooled incidence of TB-IRIS in adults with HIV-associated TB initiating ART?
18%
## Footnote
Mortality attributed to TB-IRIS occurs in about 2% of cases.
170
What are recognized risk factors for paradoxical TB-IRIS?
* Low CD4 count <100 cells/mm3
* High HIV viral load
* Disseminated or extrapulmonary TB
* Short interval between TB treatment and ART initiation
## Footnote
Early ART increases the risk for TB-IRIS.
171
What is a recommended preventive treatment for high-risk patients regarding TB-IRIS?
Pre-emptive treatment with prednisone
## Footnote
Shown to reduce the risk of paradoxical TB-IRIS.
172
How is paradoxical TB-IRIS typically managed?
* Symptomatic therapy
* Anti-inflammatory therapy (e.g., prednisone)
* Needle aspiration for large abscesses
## Footnote
Most cases are self-limiting.
173
What characterizes unmasking TB-IRIS?
Accelerated and inflammatory presentation of previously unrecognized TB at ART initiation
## Footnote
Symptoms can resemble bacterial pneumonia.
174
What interventions may decrease the risk of recurrent TB among people with HIV?
* Longer TB treatment regimens
* Daily therapy throughout treatment phases
* Post-treatment isoniazid therapy
* Use of ART
## Footnote
Evidence mainly supports these in high-burden settings.
175
What is the recommended TB screening for pregnant individuals with HIV?
Testing for TB during pregnancy if no prior negative results are documented
## Footnote
TB rates are higher in pregnant and postpartum women.
176
What are the findings regarding isoniazid preventive therapy (IPT) during pregnancy?
Increased adverse pregnancy outcomes compared to postpartum initiation
## Footnote
However, some studies found no increased risk.
177
What should be considered when prescribing prednisone to patients on rifampin?
Adjust the dosing of prednisone
## Footnote
Rifampin increases clearance of prednisolone.
178
What was the outcome of studies on isoniazid given to pregnant women with HIV in South Africa?
No increased risk of adverse pregnancy outcomes was found
## Footnote
Studies also showed similar results in Botswana.
179
What is the risk of progression from LTBI to active TB disease in individuals with HIV who are not receiving ART?
10% per year
## Footnote
This risk is significantly decreased in individuals on ART.
180
What is the recommendation for pregnant people with HIV regarding ART?
They should receive ART for their own health and for prevention of perinatal transmission (AI).
181
Under what conditions can therapy for LTBI be deferred in pregnant women with HIV?
If they are receiving effective ART and have no recent TST or IGRA conversion or close household contacts with infectious TB (BIII).
182
What should pregnant people receiving isoniazid also receive?
Daily pyridoxine supplementation (AII).
183
What is the recommendation regarding pyrazinamide use in pregnant individuals?
Its safety data is limited, but it is recommended based on individual patient considerations.
184
What is the minimum duration of TB therapy with isoniazid, rifampin, and ethambutol for drug-susceptible TB?
9 months (AII).
185
Is isoniazid teratogenic in animals or humans?
No, it is not teratogenic.
186
What is the recommendation for TB therapy in pregnant individuals?
TB therapy should not be withheld due to pregnancy (AIII).
187
What potential risk is associated with isoniazid during pregnancy?
Increased hepatotoxicity.
188
What has been observed regarding the use of bedaquiline in pregnancy?
Increased frequency of low birthweight among children exposed in utero.
189
Is ethambutol teratogenic in humans?
No evidence of teratogenicity has been observed in humans.
190
What should be monitored during pregnancy for those taking linezolid?
Complete blood counts for anemia and thrombocytopenia.
191
What is the recommendation regarding the use of fluoroquinolones in pregnant individuals?
Typically not recommended due to concerns of arthropathy, but can be used if required based on susceptibility testing (BII).
192
What potential issues are associated with aminoglycosides during pregnancy?
Risk of vestibulocochlear nerve toxicity and hearing loss in infants.
193
What is the current status of rifapentine use in pregnant individuals?
Not currently recommended due to limited data.
194
What complications can arise from TB in pregnant women?
Preterm birth, low birthweight, and fetal growth restriction.
195
What diagnostic evaluation for TB disease is the same for pregnant and nonpregnant adults?
Sputum testing and chest radiographs with abdominal shielding.
196
What is the recommendation when considering pyrazinamide inclusion in treatment regimens for pregnant individuals?
Consultation among obstetricians, TB specialists, and the patient is necessary.
197
What is the risk associated with ethionamide use during pregnancy?
Increased risk for several anomalies in rats after high-dose exposure.
198
What is the recommendation for managing MDR TB in pregnancy?
Manage in consultation with a specialist.
199
What are the potential risks associated with using delamanid in pregnancy?
Limited data on safety, but appears favorable in small cohorts.
200
What is the concern with para-aminosalicylic acid during pregnancy?
Possible increase in limb and ear anomalies reported.
