Pediatric TB latest guidelines 2023.pptx

Latest Pediatric TB guidelines

1. Pediatric TB

2. Presumptive Pediatric TB Presumptive Pediatric TB refers to children suspected to be suffering from TB based on any of the following symptoms: persistent fever cough for more than two weeks loss of weight. A definite weight loss (>5% loss in the past three months) failure to gain weight in the past three months despite adequate nutrition with no other apparent cause. In a symptomatic child, contact with a person with any form of active TB within the last two years may be deemed significant.

3. Chest Imaging A plain radiograph with a frontal view of the chest is the initial investigation advised. Radiological findings considered highly suggestive of tuberculosis include Miliary shadows –diffuse micronodular shadows affecting both the lungs like a snowstorm Intrathoracic lymphadenopathy (usually seen as a dense well-circumscribed ellipsoid or rounded shadows in the hilar or mediastinal regions) Chronic fibro-cavitary shadows (usually, but not exclusively, seen in the apical regions) Findings like consolidations, in-homogenous shadows or bronchopneumonia, etc. are considered non-specific as they may also be seen in other bacterial diseases.

4. Microbiological Tests The new strategy is to test all TB patients upfront for resistance, particularly rifampicin using NTEP-approved rapid NAAT on relevant body specimens. For pulmonary TB, respiratory secretions like self-expectorated sputum or induced sputum or gastric aspirate or lavage, etc., can be used The available initial diagnostic tests are NTEP approved rapid NAAT ( Xpert Rif™ - a cartridge-based nested NAAT for detecting M.tb and its resistance to Rifampicin; Truenat ™ M.tb Plus – a chip-based NAAT to detect M.tb and then sequentially test for Rifampicin resistance using M.tb Rif Dx™).

5. Tuberculin Skin Test & IGRA Tuberculin Skin Test (TST) is an intradermal injection of Purified Protein Derivative (PPD). The current recommendation is to use 2TU PPD RT23 for all diagnostic purposes. Mantoux’s test or PPD skin test is considered positive if the induration is 10 mm or more. In HIV co-infected cases, 5 mm may be taken as the cut-off. Positive test indicates present or past infection with M.tb . but cannot distinguish infection from disease.

6. Extrapulmonary TB TB Lymphadenitis Tuberculous Pleural Effusion Abdominal TB Tubercular Meningitis Spinal TB or Pott’s Spine

7. Case Definitions New Cases : A TB patient who has never had treatment for TB or has taken anti-TB drugs for less than one month is considered a new case. Previously Treated Cases : Recurrent TB case - A TB patient previously declared as successfully treated (cured/treatment completed) and is subsequently found to be microbiologically confirmed TB case. Treatment After Failure Case - Patients are those who have previously been treated for TB and whose treatment failed at the end of their most recent course of treatment. Treatment After Lost to Follow UP Case - A TB patient was previously treated for TB for one month or more and was declared lost to follow up in their most recent course of treatment and subsequently found a microbiologically confirmed TB case. Other Previously Treated Case - are those who have previously been treated for TB but without outcome after their most recent course of treatment is unknown or undocumented.

8. Treatment of Rifampicin Sensitive TB Type of Patients New microbiologically confirmed RS Pulmonary TB New Clinically diagnosed Pulmonary TB (Probable RS-TB) New microbiologically confirmed RS extra-pulmonary TB New Clinically Diagnosed extra-pulmonary TB (Probable RS-TB) Drug sensitive Previously Treated TB (Recurrent, Treatment after loss to follow up, Treatment after Failure) Regimen 2HRZE+ 4HRE

9. Drug Doses Drugs Range (mg/kg/day) Average (mg/kg/day) Maximum Dose Rifampicin R 10-20 15 600 Isoniazid H 7-15 10 300 Pyrazinamide Z 30-40 35 2000 Ethambutol E 15-25 20 1500

10. Adjunctive Therapy Pyridoxine therapy: Supplementation with 10 mg/day is recommended for all patients receiving INH-containing regimens. Steroids in TB: Steroids decrease inflammation-related injury and shown to reduce morbidity (sequelae) and even mortality in cases of TB when given for appropriate indications.

11. Preventive Therapy to Neonate TB Preventive therapy is recommended for neonates born to mothers with any form of active TB in pregnancy or after birth. INH preventive therapy is given in a dose of 10 mg/kg for six months, and Pyridoxine may be prescribed. However, if the neonate has been exposed to an MDR contact, then TB preventive therapy is not recommended. Separation of mother and EBM feeding.

12. Household Contacts All HHC of pulmonary TB patients (bacteriologically confirmed) should be given TPT after ruling out TB regardless of their age. In children HHC under five years of age, TPT will be offered after ruling out active TB without TBI testing. In children, HHC >five years and adolescents, chest X-Ray and TBI testing would be offered wherever available. All efforts need to be made to ensure that CXR & TBI testing is made available. However, TPT must not be deferred in their absence. (This includes close contacts of pulmonary TB patients at the workplace and other settings, regardless of their age).

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