6/10/2018 1 Pediatric Tuberculosis Rafael E. Hernandez, MD PhD Attending Physician, Instructor Pediatric Infectious Diseases Seattle Children’s Hospital & University of Washington Disclosures • No financial conflicts related to content in this presentation • Off-label use: • HZRE regimens are FDA approved for use in children • BUT particular combinations or antibiotics used in drug-resistant TB (eg. fluoroquinolones) may be off label – (not approved for TB or not approved in children). I will only focus on uses consistent with national and international guidelines.
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6/10/2018
1
Pediatric Tuberculosis
Rafael E. Hernandez, MD PhD
Attending Physician, Instructor
Pediatric Infectious Diseases
Seattle Children’s Hospital & University of Washington
Disclosures
• No financial conflicts related to content in this presentation
• Off-label use: • HZRE regimens are FDA approved for use in children
• BUT particular combinations or antibiotics used in drug-resistant TB (eg. fluoroquinolones) may be off label – (not approved for TB or not approved in children). I will only focus on uses consistent with national and international guidelines.
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Risk of Complacence Towards Childhood TB
• Uncommon: 387 cases in children < 15yo in U.S. (CDC 2016)
• Typically contagious risk is lower than adult cases• Paucibacillary disease is common – often smear negative
• Diagnosis is difficult• Cultures often difficult to obtain and lower yield
• More reliance on clinical diagnosis
• BUT….
Large Global Burden of Pediatric TB
• Approx 1 million new cases in 2016 (<15yo) and 252K pediatric deaths (201K HIV neg)
• 1.3 million household contacts <5yo worldwide
• Estimated 20-40% of cases in high burden nations are children under age 15 yo
• Indirect impact
• >9 million orphans worldwide from TB
• Loss of family income if parent diagnosed (average 60%)
AND…
(WHO 2017, Swaminathan and Rekha 2010)
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Additional reasons for concern
• Young children are at increased risk for severe or disseminated disease (meningitis, miliary TB)
• Sentinel public health event –• Likely recent/ongoing transmission
• Limited circle of contacts
• Opportunity to identify infectious cases in community
Natural History of Pediatric TB
Incubation
HypersensitivityOccult Bacteremia
Milary TBTBM
Segmental lesionPleural dz
Osteo-articular dzAdult-type dz
Reactivation
Marais, et al 2004Based on Wallgreen, 1948
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Risk of Disease Correlates with Age
No clear assoc. between age and risk of initial infection w/TB
BUT risk of disease is increased in very young
Highest progression to active disease in infants (<1 yo): • Disease risk 30-50%• TB Meningitis or miliary disease in 10-20%• Mortality risk 5-10% in infants < 1 yo
Lowest risk in 5-10 yo• Overall 2%, <0.5% disseminated
Older children develop adult like diseaseMarais, et al 2004
Objectives for Lecture
• Explain the key differences in clinical presentation, diagnosis (including interpretation of chest x-rays) and infection control concerns in children vs. adults
• Plan treatment courses for TB disease and LTBI in children
• Identify strategies to make medication dosing in children more effective/tolerable
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Review Four Basic Clinical Scenarios
• Infection control related to child with possible TB disease
• Screening healthy children
• Screening, evaluation & treatment of contacts to contagious TB cases
• Evaluation & treatment of symptomatic children
Transmission
• Generally airborne droplet route (<10 uM)
• Smear positive status is most effective marker of infectiousness
• Most childhood TB is smear negative, with lower bacterial burdens (less than 15% smear positive)
• One series at Texas Children’s Hosp:• 7 of 59 children potentially infectious
(5 smear positive)
• 15% of family caregivers have undiagnosed TB
Cruz, et al 2011.
Auramine-O
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For once children are not the vectors of disease!!!
To understand the epidemiology of childhood TB, you need to understand the epidemiology of adult TB in your community
Epidemiology in King County (2017 Data)
• 4.5 per 100K (2016) vs. 3 for WA
• Majority of cases foreign born (84%)
• 27% of cases resistant to ≥ 1 drug
• At Seattle Children’s – almost all pediatric cases foreign born or with foreign born household contact
TB case rate per 100,000 population by age group, 2012-2016, King County, WA
2013 2014 2015 2016 2017
0-17 1.2 1.9 1.4 1.6 0.9
18-44 5.4 5.8 5.3 5.3 4.8
45-64 7.5 4.5 3.3 4.6 5.0
65+ 10.9 8.5 11.8 8.8 8.6
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Epidemiology Childhood TB in United States
• Observational x-sectional study at 20 U.S. sites 2005-6
(Pang, et al. Pediatrics 2014 cases in children < 5yo)
• 83% of Cases in US Born Children (vs. adults)
• Estimated TB Rates per 100K children:• 2.57 All Children
• 24.03 Foreign-born children
• 4.81 US born with ≥ 1 foreign born parent
• 0.75 US born, with US born parents
• Source cases most often in home/family (85% with identified source)
Screen all children with HIV or other risk for TB progression
Screen asymptomatic children in the US w/ risk questionnaire
▪ Should be done at 2 wk, 6 mo, 12 mo, annual WCCs
▪ Has a family member or contact had TB disease?
▪ Has a family member had a positive tuberculin skin test result?
▪ Was your child born in a high-risk country? (countries other than the
U.S., Canada, Australia, New Zealand, or Western/Northern Europe)
▪ Has your child traveled (had contact with resident populations) to a
high-risk country for more than 1 week?
▪ Consider asking about close contact with other high risk populations
(homeless, prison, HIV + persons, foreign visitors)
THESE QUESTIONS REFLECT EPIDIMEOLOGY
Test children responding YES (with a NEW risk)
Targeted TB Screening in US
Based on AAP RedBook
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AAP RedBook 2015 IGRA vs. TST
Reminder:TB antigens in IGRA are not present in BCG vaccine or common NTM pathogens
Some experts believe IGRA ok in 3-4 yo
Interpretation of TST?Similar to adults, + if:
5 mm or greater
• Close contact with known or potentially contagious people with tuberculosis disease
• Suspected to have tuberculosis disease:
• Findings on chest x-ray c/w active or previous TB disease
• Clinical evidence of tuberculosis disease (exam or lab)
• Children receiving immunosuppressive therapy (corticosteroids, anti-TNF agents) or with immunosuppressive conditions, including HIV infection
AAP RedBook
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Interpretation of TST? (cont.)
10 mm or greater• Children at increased risk of disseminated TB disease:
• Children younger than 4 years of age• Children with other medical conditions, including Hodgkin disease,
lymphoma, diabetes mellitus, chronic renal failure, or malnutrition• Children with likelihood of increased exposure to TB disease:
• Children born in high-prevalence regions• Children who travel to high-prevalence regions• Children frequently exposed to adults who are HIV infected,
homeless, users of illicit drugs, residents of nursing homes, incarcerated or institutionalized
15 mm or greater• Children ≥ 4 years without any risk factors (Generally do not need
testing – but sometimes required by schools, volunteer positions, etc.)
Live virus vaccine in prior 4-6 weeks is contraindication to TST (and IGRA)
• MMR vaccine known to blunt response to PPD(assume similar effect on IGRAs)
• Give at same time as TST
• OR WAIT 4-6 weeks post vaccine
• No data for other live viral vaccines (Varicella, Influenza, Yellow Fever) – general rec is wait 4-6 weeks
• No evidence that inactivated/subunit vaccines affect TST
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Should prior receipt of BCG vaccine affect your interpretation of TST?
GENERALLY NOBut multiple factors affect how individuals who received BCG react to TST and subsequent clinical action:
• Age at receipt of BCG• Time since receiving BCG• Number of doses of BCG• Strain of BCG given• Symptoms consistent with TB disease• Known exposure (more likely to represent TB infection)• CXR findings consistent with current or past disease
• General Rule: TEST ONLY IF YOU WOULD TREAT POSITIVES
How should a patient with a positive TST or IGRA be treated?
Determine Latent TB Infection (LTBI) vs. TB Disease•Focused History & Physical for signs and symptoms:
• Cough > 2 weeks w/o improvement• Fever > 1 week/night sweats (maybe shorter)• Neurologic symptoms (persistent irritability)• Fatigue/malaise• Weight loss OR Failure to thrive (Review growth charts!)• Symptoms in family/contacts• Physical Exam:
• Lung findings- uncommon (rales, “wheeze” from nodes compressing airway)
• Sent to ED for evaluation, with elevated inflammatory markers
• FH/SH: Paternal GF visiting from Nigeria x 6 wks, had stomach illness. Patient is US born to Nigerian parents.
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CXR
Specimens for Culture
• Expectorated sputum• Induced sputum
• can be done in young children with RT expertise
• Gastric aspirate (preferred if sputum not possible)• young children, collected in AM after NPO• Video instructions from Curry Center Website:http://www.currytbcenter.ucsf.edu/products/pediatric-tuberculosis-guide-gastric-aspirate-procedure
• Tissue (Lymph node, bone, synovial fluid, pleura)• CSF (if any neurologic concerns especially under 2 yo and should
be considered in all children less than 1 yo undergoing TB w/u)
• RELATIVES/CONTACTS
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Algorithm for Diagnosis(preadolescent children)
Positive TST/IGRA TB symptoms or close contact
Clinical and CXREvaluation
Abnormal
IGRA/TST(negative result not useful)
Normal
Treat for LTBIas indicated Consistent with TB
Collect culturesStart 4 Drug Therapy
More consistent with another Dx
Very stable condition?No
Yes
Consider TB culturesWork-up /treat other Dx
Avoid INH or FQs
Reassess at least weeklyResponse to non-TB therapy?
Other signs/sx
Other Dx conformed or inconsistent with TB
Assess for Extrapulmonary Tuberculosis
• TB Meningitis — meningitis not responding to antibiotics, with a subacute onset, communicating hydrocephalus, stroke, and/or elevated intracranial pressure
• TB Adenitis — painless, fixed, enlarged lymph nodes, especially in the cervical region, with or without fistula formation (may also be Non-TB mycobacteria)
Pleural TB
Pericardial TB
Abdominal TB
TB of bone/joints
Vertebral TB
Skin
Renal
Eye
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Decision to treat
• Most childhood TB is SMEAR Negative in young children
• Culture yield is likely only 30-60% (Negative micro evaluation does not rule out TB in children)
• Diagnosis made on combination of clinical suspicion, possible contacts, TST/IGRA (only positive is helpful), ruling out other likely diagnoses, and response to treatment
• If you have high clinical suspicion TREAT!
• You will end up treating some children for TB who in fact have another diagnosis
General note: 10% above or below range is acceptableIntermittent dosing (2-3 x weekly) is possible in continuation phase but there is less evidence than in
adults to support practice – see CDC/WHO guidelinesRegimens for Extrapulmonary TB: are the same, but some experts recommend aminoglycoside or ethionamide in place of EMB for meningitis
*contains sorbitol- risk of GI upset/diarrhea (consider crushing tablets)
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Important follow-up
• Provide DOT whenever possible
• Assess compliance and challenges (multiple daily medications can be hard, especially in a toddler)
• Are sign/symptoms improving?
• Monitor for side effects, include family education?
• DO MEDS NEED ADJUSTMENT FOR WEIGHT?
Assessment of response/duration of treatment:
• Typical duration 6-9 months
• Follow-up cultures difficult: use CXR (2 mo – will not be normal, should not be worse) and clinical symptoms
• 12 months for osteo-articular disease or meningitis
First Line Drugs: Adverse Effects
Drug Adverse Effects Monitoring
Isoniazid Hepatotoxicity
RashPeripheral neuropathyPsychosis
JaundiceLiver enzymes PRNClinical observation, symptomsConsider need for B6, symptoms
Rifampin Orange body fluidsHyperbilirubinemiaHepatotoxiticy
Ethambutol Optic neuritis Visual exam if able (but optic neuritis is rare in children)
Usually baseline labs are drawn, but subsequent labs are only checked if symptoms, other hepatotoxic drugs, or other baseline conditions (such as liver disease)
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Suggestions for medication administration
• It may take a little while to get the child in a routine – avoid establishing a power struggle
• If they can take pills that will be easiest, practice with small candy and have a reward system• Try tipping head forward for capsules and back for tablets
• If they can do capsules but not tablets, consider crushing tabs and filling empty capsules
• Crushed pills/capsules can be mixed in food• Practice first without medicine, then with crushed candies
• Chocolate syrup, jelly/jam, apple sauce, peanut butter
• Crush and suspend in liquid (water) and give with syringe or medication pacifier
Guidance for national tuberculosis programmes on the management of tuberculosis in children – 2nd ed.http://www.who.int/tb/publications/childtb_guidelines/en/
AAP Red Book:http://aapredbook.aappublications.orgRed Book 2015: 736-759. (2018 DUE SOON)
CDC, ATS and IDSA Guidelines, 2003http://www.idsociety.org/IDSA_Practice_Guidelines/
Call: Seattle Children’s ID ServiceOr your local children’s hospital