Prevention/Infection Control
Any significant suspicion of active pulmonary TB should prompt placement in an AII room
with negative pressure isolation. Patients should be educated about the purpose of such
isolation and instructed to cover their nose and mouth when coughing or sneezing, even when
in the room. If the patient must leave the room, a surgical mask must be worn. All other
persons entering the room must use respiratory protection, usually an N95 mask (66).
Doors must be kept closed and negative pressure should be verified daily. Anterooms
are desirable, but not required; when present, the door to the anteroom and the door to the AII
room should not be opened simultaneously. There must be at least 6 air exchanges per hour;
12 or more exchanges per hour are preferred and are required for any renovation or new
construction. Air should be exhausted to the exterior, removed from any intake vents; if
recirculation to general ventilation is unavoidable, HEPA filters must be installed in the
exhaust ducts (66).
A patient may be transferred from an AII room to another hospital room when he/she is
being effectively treated for TB, is improving clinically, and three consecutive sputum samples,
obtained on different days, are smear-negative for AFB. For patients with initially negative
AFB smears, at least two weeks of TB treatment should be administered before isolation is
discontinued. If three additional specimens can be obtained at this time, they should all be AFB
negative. Maintaining AII isolation throughout hospitalization is strongly recommended for
patients with MDR-TB, cavitary lesions, or laryngeal TB (66). Most health care facilities have
hospital-specific guidelines that should be consulted and followed.
REFERENCES
- Chapman CB, Whorton CM. Acute generalized miliary tuberculosis in adults. A clinicopathological
study based on sixty-three cases diagnosed at autopsy. N Engl J Med 1946; 235:239–248. - Alvarez S, McCabe WR. Extrapulmonary tuberculosis revisited: a review of experience at Boston City
and other hospitals. Medicine (Baltimore) 1984; 63:25–55. - Sharma SK, Mohan A, Sharma A, et al. Miliary tuberculosis: new insights into an old disease. Lancet
Infect Dis 2005; 5:415–430. - Shafer RW, Kim DS, Weiss JP, et al. Extrapulmonary tuberculosis in patients with human
immunodeficiency virus infection. Medicine (Baltimore) 1991; 70:384–397. - CDC. Reported Tuberculosis in the United States, 2006. Atlanta, GA: U.S. Department of Health and
Human Services, CDC, October 2007. Available at: http://www.cdc.gov/tb/surv/surv2006/pdf/
FullReport.pdf. Accessed on October 14, 2008 - Smith S, Jacobs RF, Wilson CB. Immunobiology of childhood tuberculosis: a window on the ontogeny
of cellular immunity. J Pediatr 1997; 131:16–26. - Hussey G, Chisholm T, Kibel M. Miliary tuberculosis in children: a review of 94 cases. Pediatr Infect
Dis J 1991; 10:832–836. - Jacques J, Sloan JM. The changing pattern of miliary tuberculosis. Thorax 1970; 25:237–240.
- Anon. Miliary tuberculosis: a changing pattern. Lancet 1970; 1:985–986.
- Sime PJ, Chilvers ER, Leitch AG. Miliary tuberculosis in Edinburgh—a comparison between
1984–1992 and 1954–1967. Respir Med 1994; 88:609–611. - Federmann M, Kley HK. Miliary tuberculosis after extracorporeal shock-wave lithotripsy. N Engl J
Med 1990; 323:1212. - Morano Amado LE, Amador Barciela L, Rodriguez Fernandez A, et al. Extracorporeal shock wave
lithotripsy complicated with miliary tuberculosis. J Urol 1993; 149:1532–1534 - Anyanwu CH, Nassau E, Yacoub M. Miliary tuberculosis following homograft valve replacement.
Thorax 1976; 31:101–106. - Yekanath H, Gross PA, Vitenson JH. Miliary tuberculosis following ureteral catheterization. Urology
1980; 16:197–198. - Miller RA, Lanza LA, Kline JN, et al. Mycobacterium tuberculosis in lung transplant recipients. Am J
Respir Crit Care Med 1995; 152:374–376. - Qunibi WY, al-Sibai MB, Taher S, et al. Mycobacterial infection after renal transplantation—report of
14 cases and review of the literature. Q J Med 1990; 77:1039–1060. - Mazade MA, Evans EM, Starke JR, et al. Congenital tuberculosis presenting as sepsis syndrome: case
report and review of the literature. Pediatr Infect Dis J 2001; 20:439–442. - Ahuja SS, Ahuja SK, Phelps KR, et al. Hemodynamic confirmation of septic shock in disseminated
tuberculosis. Crit Care Med 1992; 20:901–903.
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