Publish in this journal
Journal Information
Vol. 46. Issue 5.
Pages 255-274 (May 2010)
Share
Share
Download PDF
More article options
Vol. 46. Issue 5.
Pages 255-274 (May 2010)
Consensus document
DOI: 10.1016/S1579-2129(10)70061-6
Full text access
Consensus Document on the Diagnosis, Treatment and Prevention of Tuberculosis
Documento de consenso sobre diagnóstico, tratamiento y prevención de la tuberculosis
Visits
...
Julià González-Martína,??
Corresponding author
gonzalez@clinic.ub.es

Corresponding author.
, José María García-Garcíab, Luis Anibarroc, Rafael Vidald, Jaime Estebane, Rafael Blanquerf, Santiago Morenog, Juan Ruiz-Manzanoh
a Servei de Microbiologia, Institut Clínic de Diagnòstic Biomèdic (CDB), Hospital Clínic, Institut Clínic de Diagnòstic Biomèdic August Pi Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
b Sección de Neumología, Hospital San Agustín, Avilés, Asturias, Spain
c Unidade de Tuberculose, Servicio de Medicina Interna, Complexo Hospitalario de Pontevedra, Pontevedra, Spain
d Servicio de Neumología, Hospital Vall d’Hebron, Barcelona, Spain
e Servicio de Microbiología, Fundación Jiménez-Díaz, Madrid, Spain
f Servicio de Neumología, Hospital Universitario Dr. Peset, Valencia, Spain
g Servicio de Enfermedades Infecciosas, Hospital Ramón y Cajal, Madrid, Spain
h Servicio de Neumología, Hospital Universitario Germans Trias i Pujol, Badalona, Barcelona, Spain
Article information
Abstract

Pulmonary tuberculosis must be suspected in patients with respiratory symptoms longer than 2–3 weeks. Immunosuppression may modify the clinical and radiological presentation. The chest X-ray is highly suggestive of tuberculosis (TB), but is occasionally atypical. The complex radiological tests (CT scan, MRI) are more useful in extrapulmonary TB.

At least 3 consecutive representative samples from the clinical location are used for diagnosis, whenever possible. Bacilloscopy and liquid medium cultures are indicated in all cases. Genetic amplification techniques are coadjuvant in moderate or high suspicion of TB.

In new cases of TB, administration of isoniazid, rifampin, ethambutol, and pyrazinamide (HREZ) for 2 months and isoniazid plus rifampin for 4 months is recommended. For meningitis cases, treatment should continue for up to 12 months, and up to 9 months in spinal TB with neurological affectation and silicosis. Appropriate adjustments with antiretroviral treatment must be made in HIV patients. Combined therapy is recommended to prevent development of resistance. An antibiogram for first line drugs should be performed in all initial extractions from new patients. Treatment control is one of the most important activities in TB management.

The Tuberculin Skin Test (TST) is positive in TB infection when ≥ 5mm, and Interferon-Gamma Release Assays (IGRA) are recommended in combination with TST. The standard treatment schedule for infection is 6 months with isoniazid. In pulmonary TB, respiratory isolation is applied for 3 weeks or until 3 negative bacilloscopy samples are obtained.

Keywords:
Tuberculosis
Diagnosis
Treatment
Prevention
Resumen

Debe sospecharse tuberculosis pulmonar en pacientes con síntomas respiratorios durante más de 2–3 semanas. La inmunodepresión puede modificar la presentación clínica y radiológica. La radiografía de tórax presenta manifestaciones muy sugerentes de tuberculosis, aunque en ocasiones atípicas. Las pruebas radiológicas complejas (tomografía computarizada, resonancia magnética) son más útiles en la tuberculosis extrapulmonar.

En el diagnóstico, siempre que sea posible, se utilizarán al menos 3 muestras seriadas representativas de la localización clínica. La baciloscopia y el cultivo con medios líquidos deben realizarse en todos los casos. Las técnicas de amplificación genética son coadyuvantes en la sospecha moderada o alta de tuberculosis.

En los casos nuevos de tuberculosis, se recomienda administrar isoniacida, rifampicina, etambutol y piracinamida (HREZ) durante 2 meses e isoniacida más rifampicina durante 4 meses más, con las excepciones de los casos de meningitis, en que se alargará hasta 12 meses, y de la tuberculosis espinal con afección neurológica y la silicosis, hasta 9 meses. Se recomiendan las formulaciones combinadas. En pacientes con infección por el VIH deben realizarse los ajustes necesarios con el tratamiento antirretroviral. Debe realizarse antibiograma para fármacos de primera línea a todos los aislamientos iniciales de pacientes nuevos. El control del tratamiento es una de las actividades más importantes en el abordaje de la tuberculosis.

En la infección tuberculosa la prueba de tuberculina (PT) es positiva cuando es ≥ 5 mm y los métodos de detección de producción de interferón gamma (IGRA) se recomiendan en combinación con la prueba de la tuberculina. La pauta estándar de tratamiento de la infección es de 6 meses con isoniacida. En la tuberculosis pulmonar se aplicará aislamiento respiratorio durante 3 semanas o hasta obtener 3 muestras con baciloscopia negativa.

Palabras clave:
Tuberculosis
Diagnóstico
Tratamiento
Prevención
Full text is only aviable in PDF
References
[1.]
WHO Report 2009. Global Tuberculosis Control: epidemiology, strategy, financing. World Health Organization. WHO/HTM/TB/2009.411. WHO Report; 2008.
[2.]
Surveillance of Tuberculosis in Europe-Euro TB. Report on tuberculosis cases notified in 2006. Institut de Veille Sanitaire, Saint Maurice, France. March 2008. Available from: www.eurotb.org.
[3.]
M.S. Jiménez, M. Casal.
Grupo Español de Micobacteriología (GEM). Situación de las resistencias a fármacos de Mycobacterium tuberculosis en España.
Rev Esp Quimioter, 21 (2008), pp. 22-25
[4.]
Anti-tuberculosis Drug Resistance in the World. Report no.4. The WHO/IUATLD Global Project on anti-tuberculosis Drug Resistance Surveillance 2002-2007. World Health Organization; 2008.
[5.]
P.A. Gross, T.L. Barrett, P. Dellinger, P.J. Krause, W.J. Martone, J.E. McGowan, et al.
Purpose of quality standards for Infectious Diseases.
Clin Infect Dis, 18 (1994), pp. 421
[6.]
Centers for Diseases Control and Prevention.
Extensively Drug-Resistant TB. US 1993-2006.
MMWR, 56 (2007), pp. 250-253
[7.]
American Thoracic Society.
Centers for Disease Control and Prevention and Infectious Diseases Society of America. Targeted tuberculin testing and treatment of latent tuberculosis infection.
Am J Respir Crit Care Med, 161 (2000), pp. S221-S247
[8.]
Grupo de trabajo del área TIR de SEPAR Recomendaciones SEPAR.
Normativa sobre la prevención de la tuberculosis.
Arch Bronconeumol, 38 (2002), pp. 441-451
[9.]
J. Ruiz-Manzano, R. Blanquer, J. Calpe, J.A. Caminero, J. Cayla, J.A. Domínguez, et al.
Normativa SEPAR sobre diagnóstico y tratamiento de la tuberculosis.
Arch Bronconeumol, 44 (2008), pp. 551-556
[10.]
S. Moreno, R. Blázquez, A. Novoa, I. Carpena, A. Menasalvas, C. Ramírez, et al.
The effect of BCG vaccination on tuberculin reactivity and the booster effect among hospital employees.
Arch Intern Med, 161 (2001), pp. 1760-1765
[11.]
M. Farhat, C. Greenaway, M. Pai, D. Menzies.
False-positive tuberculin skin tests: what is the absolute effect of BCG and non-tuberculous mycobacteria?.
Int J Tuberc Lung Dis, 10 (2006), pp. 1192-1204
[12.]
M. Pai, A. Zwerling, D. Menzies.
Systematic review: T-cell-based assays for the diagnosis of latent tuberculosis infection: an update.
Ann Intern Med, 149 (2008), pp. 177-184
[13.]
L. Richeldi.
An update on the diagnosis of tuberculosis infection.
Am J Respir Crit Care Med, 174 (2006), pp. 736-742
[14.]
J. Domínguez, J. Ruiz-Manzano, M. De Souza-Galvão, I. Latorre, C. Milà, S. Blanco, et al.
Comparison of two commercially available interferon-gamma blood tests for immunodiagnosis of tuberculosis infection.
Clin Vaccine Immunol, 15 (2008), pp. 168-171
[15.]
B.M. Mayosi, L.J. Burgess, A.F. Doubell.
Tuberculous pericarditis.
Circulation, 112 (2005), pp. 3608-3616
[16.]
A.A. Cagatay, Y. Caliskan, S. Aksoz, L. Gulec, S. Kucukoglu, Y. Cagatay, et al.
Extrapulmonary tuberculosis in immunocompetent adults.
Scand J Infect Dis, 36 (2004), pp. 799-806
[17.]
Z. Yang, Y. Kong, F. Wilson, B. Foxman, A.H. Fowler, C.F. Marrs, et al.
Identification of risk factors for extrapulmonary tuberculosis.
Clin Infect Dis, 38 (2004), pp. 199-205
[18.]
Centers for Diseases Control and Prevention. Guidelines for the investigation of contacts of persons with infectious tuberculosis;recommendations from the national Tuberculosis Controllers Association and CDC, and Guidelines for using QuantiFERON®-TB Gold test for detecting Mycobacterium tuberculosis infection. United States. MMWR. 2005;54:1-55.
[19.]
Grupo de Estudio de contactos de la Unidad de Investigación en Tuberculosis de Barcelona (UITB).
Documento de Consenso sobre el estudio de contactos en los pacientes tuberculosos.
Med Clin (Barc), 112 (1999), pp. 151-156
[20.]
National Collaborating Centre for Chronic Conditions. Tuberculosis: clinical diagnosis and management of tuberculosis, and measures for its prevention and control. London: Royal College of Physicians; 2006. Available from: http://www.nice.org.uk/nicemedia/pdf/CG033FullGuideline.pdf
[21.]
E. Nohrström, E. Kentala, P. Kuusela, P.S. Mattila.
Tuberculosis of the head and neck in Finland.
Acta Oto-Laryngol, 127 (2007), pp. 770-774
[22.]
C. Daley.
The typically “atypical” radiographic presentation of tuberculosis in advanced HIV disease.
Tuberc Lung Dis, 76 (1995), pp. 475-476
[23.]
M. Narita, D. Ashkin, E. Hollender, A. Pitchenik.
Paradoxical worsening of tuberculosis following antiretroviral therapy in patients with AIDS.
Am J Respir Crit Care Med, 158 (1998), pp. 157-161
[24.]
E. Navas, P. Martín-Dávila, L. Moreno, V. Pintado, J.L. Casado, J. Fortún, et al.
Paradoxical reactions of tuberculosis in AIDS patients treated with highly active antiretroviral therapy.
Arch Intern Med, 162 (2002), pp. 97-99
[25.]
J. DeSimone, R. Pomerantz, T. Babinchack.
Inflammatory reactions in HIV-1- infected persons after initiation of highly active antiretroviral therapy.
Ann Intern Med, 133 (2000), pp. 447-454
[26.]
G. Meintjes, R. Wilkinson, C. Morroni, D. Pepper, K. Rebe, M. Rangaka, et al.
Randomized placebo-controlled trial of prednisone for the TB immune reconstitution inflammatory syndrome. 16 Conferences on Retroviruses and Opportunistic Infections.
Montreal, (2009),
[27.]
A.N. Leung.
Pulmonary tuberculosis: the essentials.
[28.]
D.M. Hansell, P. Dee.
Infections of the lung and pleura. Cap V.
Imaging of diseases of the chest, 3th ed., pp. 163-263
[29.]
M.N.A. Idris.
Tuberculoma of the brain: a series of 16 cases treated with antituberculosis drugs.
Int J Tuberc Lung Dis, 11 (2007), pp. 91-95
[30.]
C. Morgado, N. Ruivo.
Imaging meningo-encephalic tuberculosis.
Eur J Radiol, 55 (2005), pp. 188-192
[31.]
D.M. Yang.
Comparison of tuberculous and pyogenic epididymal abscesses: clinical, gray-scale sonographic, and color Doppler sonographic features.
Am J Roentgenol, 177 (2001), pp. 1131-1135
[32.]
Alcaide Fernández de Vega F, Esteban Moreno J, González Martín J, Palacios Gutiérrez JJ. Micobacterias. In: Cercenado E, Cantón R, editors. Procedimientos en microbiología clínica. Recomendaciones SEIMC. 2.a ed.;2005. Available from: www.seimc.es.
[33.]
Pfyffer GE. Mycobacterium: general characteristics, laboratory detection and staining procedures. In: Murray PR, Baron EJ, Jorgensen JH, Landry ML, Pfaller MA, editors. Manual of clinical microbiology. 9th ed. Washington DC: ASM Press; p. 543–72.
[34.]
American Thoracic Society, Centers for Disease Control and Prevention and Infectious Diseases Society of America.
Diagnostic standards and classification of tuberculosis in adults and children.
Am J Respir Crit Care Med, 161 (2000), pp. 1376-1395
[35.]
A. Van Deun, A. Hamid Salim, K.J. Aung, M.A. Hossain, N. Chambugonj, M.A. Hye, et al.
Performance of variations of carbolfuchsin staining of sputum smears for AFB under field conditions.
Int J Tuberc Lung Dis, 9 (2005), pp. 1127-1133
[36.]
Woods GE, Warren NG, Inderlied CB. Susceptibility test methods: Mycobacteria, Nocardia and other actinomycetes. In: Murray PR, Baron EJ, Jorgensen JH, Landry ML, Pfaller MA, editors. Manual of clinical microbiology. 9th ed. Washington DC: ASM Press; p. 1223-47
[37.]
Zhang Y, Vilchèze C, Jacobs WR. Mechanisms of drug resistance in Mycobacterium tuberculosis. In: Cole ST, Eisenach KD, McMurray DN, Jacobs WR, editors. Tuberculosis and the tubercle bacillus. Washington DC: ASM Press; p. 115-40.
[38.]
S.J. Kim.
Drug-susceptibility testing in tuberculosis: methods and reliability of results.
Eur Respir J, 25 (2005), pp. 564-569
[39.]
M. Garrigó, L.M. Aragón, F. Alcaide, S. Borrell, E. Cardeñosa, J.J. Galán, et al.
Multicenter laboratory evaluation of the MB/BacT Mycobacterium detection system and the BACTEC MGIT 960 system in comparison with the BACTEC 460 TB system for susceptibility testing of Mycobacterium tuberculosis.
J Clin Microbiol, 45 (2007), pp. 1766-1770
[40.]
M.S. Diaz-Infantes, M.J. Ruíz-Serrano, L. Martínez Sánchez, A. Ortega, E. Bouza.
Evaluation of the MB/BacT Mycobacterium detection system for susceptibility testing of Mycobacterium tuberculosis.
J Clin Microbiol, 38 (2000), pp. 1988-1989
[41.]
S. Rüsch-Gerdes, G.E. Pfyffer, M. Casal, M. Chadwick, S. Siddiqi.
Multicenter laboratory validation of the BACTEC MGIT 960 technique for testing susceptibilities of Mycobacterium tuberculosis to classical second-line drugs and newer antimicrobials.
J Clin Microbiol, 44 (2006), pp. 688-692
[42.]
J. Dinnes, J. Deeks, H. Kunst, A. Gibson, E. Cummins, N. Waugh, et al.
A systematic review of rapid diagnostic tests for the detection of tuberculosis infection.
Health Technol Assess, 11 (2007), pp. 1-196
[43.]
S. Greco, E. Girardi, A. Navarra, C. Saltini.
Current evidence on diagnostic accuracy of commercially based nucleic acid amplification tests for the diagnosis of pulmonary tuberculosis.
Thorax, 61 (2006), pp. 783-790
[44.]
T. Takahashi, T. Nakayama.
Novel technique of quantitative nested real-time PCR assay for Mycobacterium tuberculosis DNA.
J Clin Microbiol, 44 (2006), pp. 1029-1039
[45.]
J. Ruiz Manzano, J.M. Manterola, F. Gamboa, A. Calatrava, E. Monsó, C. Martínez, et al.
Detection of Mycobacterium tuberculosis in paraffin-embedded pleural biopsy specimens by commercial ribosomal RNA and DNA amplifications kits.
Chest, 118 (2000), pp. 648-655
[46.]
E. Tortoli, A. Nanetti, C. Piersimoni, P. Cichero, C. Farina, G. Mucignat, et al.
Performance assessment of new multiplex probe assay for identification of Mycobacteria.
J Clin Microbiol, 39 (2001), pp. 1079-1084
[47.]
S. Ramaswamy, J.M. Musser.
Molecular genetic basis of antimicrobial agent resistance in Mycobacterium tuberculosis: 1998 update.
Tubercle and Lung Disease, 78 (1998), pp. 3-29
[48.]
M. Ruiz, M.J. Torres, A.C. Llanos, A. Arroyo, J.C. Palomares, J. Aznar.
Direct detection of rifampin- and isoniazide-resistant Mycobacterium tuberculosis in auraminerhodamine- positive sputum specimens by real-time PCR.
J Clin Microbiol, 42 (2004), pp. 1585-1589
[49.]
M. Espasa, J. González-Martín, F. Alcaide, L.M. Aragón, J. Lonca, J.M. Manterola, et al.
Direct detection in clinical samples of multiple gene mutations causing resistance of Mycobacterium tuberculosis to isoniazid and rifampicin using fluorogenic probes.
J Antimicrob Chemother, 55 (2005), pp. 860-865
[50.]
L.M. Aragón, F. Navarro, V. Heiser, M. Garrigó, M. Español, P. Coll.
Rapid detection of specific gene mutations associated with isoniazide or rifampicin resistance in Mycobacterium tuberculosis clinical isolates using non-fluorescent low-density DNA microarrays.
J Clin Microbiol, 57 (2006), pp. 825-831
[51.]
A.O. El-Zammar, A.L.A. Katxenstein.
Pathological diagnosis of granulomatous lung disease: a review.
Histopathology, 50 (2007), pp. 289-310
[52.]
L. Valdés, D. Alvarez, E. San José, P. Penela, J.M. Valle, J.M. García Pazos, et al.
Tuberculous pleuresy.
Arch Intern Med, 158 (1988), pp. 2017-2021
[53.]
Ministerio de Sanidad y Consumo. Plan para la prevención y control de la tuberculosis en España. Madrid: Ministerio de Sanidad y Consumo; 2007.
[54.]
American Thoracic Society, Centers for Disease Control and Prevention and Infectious Diseases Society of America.
Treatment of tuberculosis.
Am J Respir Crit Care Med, 167 (2003), pp. 603-662
[55.]
WHO. Treatment of tuberculosis: Guidelines for National Programmes. 3rd ed. Geneve: WHO; 2003.
[56.]
D. Burger, R. Hoetelmans, P. Koopmans, P.L. Meenhorst, J.W. Mulder, Y.A. Hekster, et al.
Clinically relevant drug interactions with antiretroviral agents.
Antiviral Ther, 2 (1997), pp. 149-165
[57.]
J. Oliva, S. Moreno, J. Sanz, E. Ribera, J.A. Molina, R. Rubio, et al.
Co-administration of rifampin and nevirapine in HIV-infected patients with tuberculosis.
[58.]
D. Pedral-Sampaio, C. Alves, E. Netto, C. Brites, A.S. Oliveira, R. Badaro.
Efficacy and safety of efavirenz in HIV patients on rifampin for tuberculosis.
Brazil J Infect Dis, 8 (2004), pp. 211-216
[59.]
E. Ribera, L. Pou, R.M. López, M. Crespo, V. Falcó, I. Ocaña, et al.
Pharmacokinetic interaction between nevirapine and rifampin in HIV-infected patients with tuberculosis.
J Acquir Immune Defic Syndr, 28 (2001), pp. 450-453
[60.]
L.F. López Cortés, R. Ruiz Valdera, P. Viciana, A. Alarcón, J. Gómez, E. León, et al.
Pharmacokinetic interactions between efaviren and rifampin in HIV-infected pateints with tuberculosis.
Clin Pharmacokinet, 41 (2002), pp. 681-690
[61.]
Panel de expertos de GESIDA y Plan Nacional sobre el Sida.
Tratamiento de las infecciones oportunistas en pacientes adultos y adolescentes infectados por el virus de la inmunodeficiencia humana en la era del tratamiento antirreteroviral de gran actividad.
Enferm Infecc Microbiol Clin, 26 (2008), pp. 356-379
[62.]
R. Tost, R. Vidal, J. Maldonado, J.A. Caylà.
Efectividad y tolerancia de las pautas de tratamiento antituberculoso sin isoniacida y/o rifampicina.
Arch Bronconeumol, 44 (2008), pp. 478-483
[63.]
C. Mitnick, J. Bayona, E. Palacios, S. Shin, J. Furin, M. Alcántara, et al.
Communitybased therapy for multidrug-resistant tuberculosis in Lima, Perú.
N Engl J Med, 348 (2003), pp. 119-128
[64.]
M.J. Smieja, C.A. Marchetti, D.J. Cook, F.M. Smaill.
Isoaniazid for preventing tuberculosis in non-HIV infected persons.
Cochrane Database of Systematic Reviews, (1999),
[65.]
S. Woldehanna, J. Volmink.
Treatment of latent tuberculosis infection in HIV infected persons.
Cochrane Database of Systematic Reviews, (2004),
[66.]
J. Ena, V. Valls.
Short-course Therapy with rifampin plus isoniazid, compared with standard therapy with isoniazid, for Latent Tuberculosis Infection: a meta-analysis.
Clin Infect Dis, 40 (2005), pp. 670-676
[67.]
N.P. Spyridis, P.G. Spyridis, A. Gelesme, V. Sypsa, M. Valianatou, F. Metsou, et al.
The effectiveness of a 9-month regime of isoniazid plus rifampin for treatment of Latent Tuberculosis Infection in children: results of an 11-year randomized study.
Clin Infect Dis, 45 (2007), pp. 715-722
[68.]
Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee. 2007 Guideline for Isolation Precautions, Preventing Transmission of Infectious Agents in Healthcare Settings, June 2007. Available from: http://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf.
[69.]
J. Esteban.
Tuberculosis in special hosts and occupational hazards.
Tuberculosis, pp. 93-111
[70.]
X. Casas, J. Ruiz-Manzano, I. Casas, F. Andreo, J. Sanz, N. Rodríguez, et al.
Tuberculosis en personal sanitario de un hospital general.
Med Clin (Barc), 122 (2004), pp. 741-743
[71.]
L. Lopez-Cerero, J. Esteban, J. González-Martín.
Revisión de la normativa y recomendaciones sobre bioseguridad en el laboratorio de micobacterias.
Enferm Infecc Microbiol Clin, 25 (2007), pp. 52-59
[72.]
T.F. Brewer.
Preventing tuberculosis with bacillus Calmette-Guérin vaccine: a metaanalysis of the literature.
Clin Infect Dis, 31 (2000), pp. S64-S67

Document published simultaneously in Infectious diseases and microbiology.

Joint consensus document from the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC) and the Spanish Society of Pneumology and Thoracic Surgery (SEPAR).

Copyright © 2010. Sociedad Española de Neumología y Cirugía Torácica
Idiomas
Archivos de Bronconeumología (English Edition)

Subscribe to our newsletter

Article options
Tools
es en

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

es en
Política de cookies Cookies policy
Utilizamos cookies propias y de terceros para mejorar nuestros servicios y mostrarle publicidad relacionada con sus preferencias mediante el análisis de sus hábitos de navegación. Si continua navegando, consideramos que acepta su uso. Puede cambiar la configuración u obtener más información aquí. To improve our services and products, we use "cookies" (own or third parties authorized) to show advertising related to client preferences through the analyses of navigation customer behavior. Continuing navigation will be considered as acceptance of this use. You can change the settings or obtain more information by clicking here.