Aglycopeptidecan be used for septicaemia associated with
MRSA.
See the management of endocarditis, osteomyelitis, or
septic arthritis associated with MRSA.
Prophylaxis with vancomycin or teicoplanin p. 325 (alone
or in combination with another antibacterial active against
other pathogens) is appropriate for patients undergoing
surgery if:
.there is a history of MRSA colonisation or infection
without documented eradication;
.there is a risk that the patient’s MRSA carriage has
recurred;
.the patient comes from an area with a high prevalence of
MRSA.
It is important that hospitals have infection control
guidelines to minimise MRSA transmission, including
policies on isolation and treatment of MRSA carriers and on
hand hygiene. See eradication of nasal carriage of MRSA in
Nose p. 694.
2.4 Tuberculosis
Tuberculosis 16-Mar-2017
Treatment phases, overview
Active tuberculosis is treated in two phases—aninitial phase
using four drugs and acontinuation phaseusing two drugs in
fully sensitive cases. Treatment requires specialised
knowledge and supervision, particularly where the disease
involves resistant organisms or non-respiratory organs.
There are two regimens recommended for the treatment of
tuberculosis in the UK; variations occur in other countries.
Either the unsupervised regimen or the supervised regimen
should be used; the two regimens shouldnotbe used
concurrently. Compliance with therapy is a major
determinant of its success. Treatment needs to be carefully
monitored in families in whom concordance may be
problematic.
Initial phase
The concurrent use of four drugs during the initial phase is
designed to reduce the bacterial population as rapidly as
possible and to prevent the emergence of drug-resistant
bacteria. The drugs are best given asfixed dose combination
preparations unless the child is unable to swallow the tablets
or one of the components cannot be given because of
resistance, intolerance or an inappropriate dose
combination. The treatment of choice for the initial phase is
the daily use of rifampicin p. 364 , ethambutol hydrochloride
p. 367 , pyrazinamide p. 368 and isoniazid p. 367 (with
pyridoxine hydrochloride p. 627 for prophylaxis of isoniazid-
induced neuropathy); modified according to drug
susceptibility testing. Treatment should be started without
waiting for culture results if clinical features or histology
results are consistent with tuberculosis; treatment should be
continued even if initial culture results are negative. The
initial phase drugs should be continued for two months.
Where a positive culture forM. tuberculosishas been
obtained, but susceptibility results are not available after
two months, treatment with rifampicin, ethambutol
hydrochloride, pyrazinamide and isoniazid (with pyridoxine
hydrochloride) should be continued until full susceptibility
is confirmed, even if this is for longer than two months.
Streptomycin p. 313 is rarely used in the UK although it
may be used in the initial phase of treatment if resistance to
isoniazid has been established before therapy is commenced
and ethambutol hydrochloride is contra-indicated, or when
patients cannot tolerate standard treatment.
Continuation phase
After the initial phase, daily treatment is continued for a
further 4 months with rifampicin and isoniazid (preferably
given as a combination preparation) with pyridoxine
hydrochloride. Longer treatment is necessary for meningitis,
direct spinal cord involvement, and for resistant organisms
which may also require modification of the regimen.Unsupervised treatment
The unsupervised treatment regimen should be used for
children who are likely to take antituberculosis drugs reliably
without supervisionby a healthcare worker. Children and
families who are unable or unlikely to comply with daily
administration of therapy should be treated with the
regimen described under Supervised Treatment.Pregnancy and breast-feeding
The standard unsupervised 6 -month treatment regimen may
be used during pregnancy. Streptomycin should not be given
in pregnancy.
The standard unsupervised 6 -month treatment regimen
may be used during breast-feeding.Neonates
Congenital tuberculosis is acquired from maternal
extrapulmonary sites at birth, particularly the genital tract; if
infection is suspected, the baby will require treatment with
rifampicin, ethambutol hydrochloride, pyrazinamide and
isoniazid (with pyridoxine hydrochloride). This regimen is
used for 2 months during the initial phase of treatment.
After the initial phase, rifampicin and isoniazid with
pyridoxine hydrochloride is continued for a further
4 months.Supervised treatment
Drug administration should befully supervisedby a
healthcare worker (directly observed therapy, DOT) in
children or families who cannot comply reliably with the
treatment regimen. If daily directly observed therapy is not
possible, a supervised dosing schedule of three times a week
should be considered. Regimens with a dosing schedule of
fewer than three times a week should not be used.
Directly observed therapy should be offered to children or
to children whose carers:
.have a history of non-adherence;
.have previously been treated for tuberculosis;
.are in denial of the tuberculosis diagnosis;
.have multidrug-resistant tuberculosis;
.have a major psychiatric or cognitive disorder;
.have a history of homelessness, drug or alcohol misuse;
.are in prison, or have been in the past 5 years;
.are too ill to self-administer treatment;
.request directly observed therapy.
Advice and support should be offered to these children and
their carers to assist with treatment completion.Immunocompromised patients
Multi-resistantMycobacterium tuberculosismay be present in
immunocompromised children. The organism should always
be cultured to confirm its type and drug sensitivity.
ConfirmedM. tuberculosisinfection sensitive tofirst-line
drugs should be treated with a standard six month regimen;
after completing treatment, children should be closely
monitored. The regimen may need to be modified if infection
is caused by resistant organisms, and specialist advice is
needed.
Specialist advice should be sought about tuberculosis
treatment or chemoprophylaxis in a child who is HIV-
positive (see alsoLatent tuberculosisbelow); care is required
in choosing the regimen and in avoiding potentially serious
interactions. Starting antiretroviral treatment in thefirst two
months of antituberculosis treatment increases the risk ofBNFC 2018 – 2019 Tuberculosis 361
Infection5