Nurse Protocol for Tuberculosis Infection Preventive Therapy
This is the most recent nurse protocol for preventive therapy by the Georgia Department of Health in Atlanta.High-risk candidates for preventive therapy:
1. People with a positive tuberculin skin test reaction in the following high-risk groups, regardless of age:
a. People known to have or suspected of having HIV infection
b. Close contacts of a person with infectious TB
c. People who have a chest radiograph suggestive of previous TB and who have received inadequate treatment
d. People who inject illicit drugs or share needles
e. People with certain medical conditions (e.g. HIV- infection, immunosuppressive therapy, hematologic or reticuloendothelial malignancies, diabetes, chronic renal failure, post gastrectomy, and malnutrition)
f. Recent tuberculin skin test converters that have converted from negative to positive within the past two years (> or equal to 10mm increase).
2. People with a positive skin test reaction who are younger than 35 years of age and in the following groups:
a. Foreign-born people in areas where TB is common
b. Medically underserved, low-income populations, including high-risk racial and ethnic groups (espe- cially blacks, Hispanics, and the American Indians/Alaska Natives)
c. Residents of long-term care facilities
d. Children younger than four years of age
e. Locally identified high-prevalence groups (e.g. migrant farm workers or homeless people)
3. Preventive therapy might not be indicated for:
a. People at increased risk for adverse reactions to isoniazid (INH) (e.g., people 35 years of age or older who are not in a risk group as noted above (groups 1 and 2) and people for whom INH is contraindicated)
b. People who cannot tolerate INH may want to use another drug (e.g. Rifampin)
c. People likely to be infected with drug-resistant TB (Note: patient should be referred to consulting physician)
d. People who are not likely to complete a course of preventive therapy (e.g., some homeless people or migrant farm workers)
Education/Counseling
1. Explain the rationale for preventive therapy and the importance of attending regularly scheduled clinic appointments.2. Explain the difference between "TB infection" and "TB disease" and what a "positive skin test" means.
3. Explain to the patient and his or her family the signs and symptoms of TB disease, and report immediately if they have symptoms.
4. Explain the symptoms of hepatitis and other adverse reactions to isoniazid. Patient should also be advised to report immediately to the nurse or clinician if any such symptoms occur during preventive therapy.
5. Explain the connection between HIV and TB.
6. Explain the importance of HIV testing for all TB-infected individuals.
Follow-Up
1. At least once a month patients receiving preventive therapy should be evaluated for:a. Adherence to the prescribed regimen
b. Symptoms of hepatitis (nausea, loss of appetite, vomiting, persistently dark urine, yellowish skin, malaise, unexplained elevated temperature for more than three days, abdominal tenderness and/or right upper quadrant tenseness)
c. Symptoms of neurotoxicity such as paresthesia of hands or feet
2. At the follow-up visits, ask patients about adherence to therapy.
3. Pill counts and urine tests can be used to check for the presence of isoniazid metabolites. (Urine tests indicate only whether isoniazid was taken in the preceding 24 hours.)
4. People who are considered high risk for hepatoxicity should have a monthly AST during the course of therapy.
5. Observe for peripheral neuropathy during the course of therapy, and report to the delegating physician if pyridoxine (Vitamin B6) is needed to correct this complaint.
6. Women, particularly black and Hispanic women, may be at increased risk for fatal hepatitis associated with INH, according to some reports. This risk may be increased during the postpartum period. These individuals should be closely monitored for adverse reactions throughout the course of treatment.
7. If any of the liver enzymes tests (AST, SGOT, liver profile tests) exceed three to five times the upper limits of normal, or if patients report symptoms of adverse reactions, discontinue the isoniazid, and report to the consulting physicians immediately.
Consultation
Consult the TB control or contract physician:1. Regarding any complications of preventive therapy with individuals placed on INH.
2. If a patient’s HIV test results are positive, or if a patient at risk refuses HIV testing.
3. About any abnormal lab test results.
Referral
1. Refer preventive therapy patients for other medical and social services as needed, particularly drug and alcohol abuse treatment.2. Refer all complicated tuberculosis preventive therapy patients to the consulting physician, (pregnant women, individuals with acute or chronic conditions, individuals infected with drug-resistant TB).
Source: Printed with permission from the Georgia Department of Public Health.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content