TB chemoprophylaxis requires diligent follow-up
July 1, 1997 4 minutes read
TB chemoprophylaxis requires diligent follow-up
By Sharon A. Watts, RN-C, MS, FNP
Nurse Practitioner
Carol C. Grove, RN, MSN
Nurse Manager
Nancy S. Dale, BSN
Adult Nurse Practitioner
Employee Health Services
University Hospitals of Cleveland
The increase in tuberculosis over the last decade has necessitated greater vigilance by hospital employee health departments to monitor for exposure and treatment follow-up.1 Record keeping and periodic changes in recommended guidelines require up-to-date information for a successful treatment program.
Our large (6,000-employee) Midwestern teaching hospital’s employee health department decided to draft a flow sheet to organize and expedite treatment follow-up of employees taking tuberculosis chemoprophylactic drugs. (See related four-page insert in this issue.) Nurse practitioners perform screening histories and physical examinations on all employees seeking care at our hospital. Medication is initiated in consultation with a physician, and monthly follow-up screening is done until completion of the medication regimen.
If employees test positive for tuberculosis, they have approximately a 10% risk for developing active TB during their lifetimes, with the greatest risk within the first two years of conversion from a previous negative purified protein-derivative (PPD) test to a positive test. A two-step process is recommended for all employees who have not had a documented negative PPD within the preceding 12 months and do not have a positive PPD history. After the initial baseline screen, PPD testing can be done annually unless the employee works in a high-risk area such as the respiratory or pulmonary division. Pregnancy is not a contraindication for PPD testing.2
Government guidelines recommend professional evaluation of PPD results.2 However, a double-blind comparison study demonstrated a 99.5% successful self-assessment reading score for firefighters (N=1833) in PPD interpretation.3 Many hospitals train selected health care professionals as designated readers of PPD test results.
Once employees are diagnosed positive by PPD using government guidelines of millimeter reaction size, age, and risk factors,2 a chest X-ray (consultation required during pregnancy), history, and physical are provided. Specific signs and symptoms of active tuberculosis are coughing, fever, night sweats, anorexia, and weight loss.2 A baseline physical exam concentrates on detecting signs of active TB such as evidence of lymphadenopathy accompanied by abnormal lung sounds, with particular attention to the apices; however, physical findings may be unremarkable early in the disease.4 A baseline determination of liver status is necessary to rule out underlying liver disease.
The American Thoracic Society notes that hepatitis is the major toxic effect of isoniazid (INH), with alcohol consumption as an identified risk cofactor.5 It is important to obtain an accurate alcohol consumption history prior to initiating chemoprophylaxis. Alcohol use during treatment is contraindicated. Employees who admit that abstaining from all alcohol ingestion for six to nine months would be a problem are followed with semiannual chest X-rays for two years. (They also are referred to the employee assistance program for assessment of alcohol use.)
If baseline liver function tests (LFTs) are normal, a prescription is given for 30 days of treatment with isoniazid. A second liver profile is checked after the first month of chemoprophylaxis. If LFTs are within normal limits and the employee denies any signs and symptoms of disease or effects from the INH, we order enough medication for three months and recheck LFTs every three months thereafter. It is important to confer with the employee on a monthly basis to rule out any active TB or medication side effects.
Most employees at our institution are started on isoniazid 300 mg every day on an empty stomach for six to 12 months, provided they were not exposed to INH-resistant tuberculosis. An empty stomach is encouraged when taking INH to decrease the incidence of nausea. Employees with other medical conditions that may predispose them to neuropathy, such as diabetes, uremia, alcoholism, and malnutrition, should be given pyridoxine 50 mg every other day. When a known exposure to a source patient who is INH-resistant occurs, consultation with infectious disease and infection control practitioners is warranted to consider an alternate treatment of chemoprophylaxis.
Our employee health nursing staff developed a flow sheet (see insert) to enable accurate tracking of employees on chemoprophylaxis for positive PPDs. Moreover, using the flow sheet has provided an efficient record-keeping system for reporting to the infection control and infectious disease departments. Flow sheets are kept in a central location and charted on when the employee returns for a routine scheduled follow-up visit. These records are reviewed periodically to ensure employee compliance. At the end of the treatment course, the flow sheet is filed in the employee’s confidential health record.
The bottom line is that employee health provi ders need to be diligent in their follow-up of employees with positive PPDs. Baseline examination and periodic evaluation for side effects of chemoprophylaxis are necessary. At our institution, use of a flow sheet condenses information and provides central access for efficient record keeping and follow-up.
References
1. Centers for Disease Control and Prevention. Essential components of a tuberculosis prevention and control program. MMWR 1995; 44(No. RR-11):1-34.
2. Centers for Disease Control and Prevention. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health care facilities, 1994. MMWR 1994; 43(No. RR-13):1-112.
3. Prezant DJ, Kelly KJ, Karwa ML, et al. Self-assessment of tuberculin skin test reactions by New York City firefighters: Reliability and cost-effectiveness in an occupational health care setting. Ann Int Med 1996; 125:280-283.
4. Isselbacher KJ, Braunwald E, Wilson J, et al, eds. Harrison’s Principles of Internal Medicine. 13th ed. New York: McGraw-Hill; 1994.
5. American Thoracic Society. Treatment of tuberculosis and tuberculosis infection in adults and children. Amer J Resp Crit Care Med 1994; 149:1359-1374.
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