TB exposure on the WARDS!

[chicamedica]

****!! MY PATIENT MAY HAVE ACTIVE TB!!!!!!!!!! I have been around her for like 5 days! 😱 😱 😱

How soon should I get a PPD placed to see if i seroconverted? Am I supposed to take like 10 drugs for 6 months now?

Has anything like this happened to anyone else?

---

Members don't see this ad.

 

[inositide]

****!! MY PATIENT MAY HAVE ACTIVE TB!!!!!!!!!! I have been around her for like 5 days! 😱 😱 😱

How soon should I get a PPD placed to see if i seroconverted? Am I supposed to take like 10 drugs for 6 months now?

Has anything like this happened to anyone else?

If your pt really has active TB (not just PPD positive), then it is possible that you will seroconvert. In case you do, you would take isoniazid for 9 months (some would argue for less). No multi drug therapy is needed for you. Check the CDC website for exposure of health care personnel to active TB patients so that your fears can be allayed.

 

[Solideliquid]

If your pt really has active TB (not just PPD positive), then it is possible that you will seroconvert. In case you do, you would take isoniazid for 9 months (some would argue for less). No multi drug therapy is needed for you. Check the CDC website for exposure of health care personnel to active TB patients so that your fears can be allayed.

Adults, HIV-negative: As the preferred regimen for tuberculosis prophylaxis, the CDC recommends isoniazid 300 mg PO once daily or 900 mg/day PO twice weekly with pyridoxine (50 mg once daily or 100 mg twice weekly) for 9 months. Prospective randomized trials of up to 12 months of therapy in individuals without HIV infection suggest that the maximal benefit of isoniazid therapy is achieved by 9 months. Although the 9-month regimen is preferred, a 6-month regimen also provides substantial protection and is superior to placebo. The shorter regimen is not recommended in patient with radiographic evidence of prior tuberculosis.[46]

From Harrisons Online.

 

[angel80]

Prior to medical school, I worked as a nurses aide at a local hospital. There was a patient that I had taken care of for a few days (don't forget nurses/nurses aides spend 12 hours a day with a patient, not 15 minutes). The patient ended up having active TB, and everyone who had come in contact with the patient had to have a PPD placed before being able to return to work. Mine ended up being negative. I was also exposed to Pertussis during my Peds month (our Pertussis vaccination only lasts up until adolescence), and had to go on prophylaxis (Z-pack) before being allowed to go back to work. Unfortunately, exposure to infectious agents is part of being a health care worker. A few of my classmates were stuck by needles and needed to be worked up for HIV/hepatitis.

 

[u_r_my_serenity]

Relax, I have been exposed to TB FOUR times since third year, and one of them was a very serious exposure (the patient lost one entire lung and 25% of the other to unchecked TB and I was in her face for 30 min at admission).

Anyway, don't get your PPD immediately or it may not be accurate. Wait 1-2 months from being exposed. If your PPD is positive and you are otherwise healthy, you will have to take isoniazid for 6 months (or sometimes 9 months).

A CXR will be a good idea in about 2 years from exposure. That is about how long it takes from exposure for an active infection to show up radiographically. If you test positive on PPD and take care of it then your chances of developing an active infection are extremely low. Further, you cannot infect anyone around you with a latent infection, only an active one.

Many physicians have been/will be exposed. It will not stop you from doing anything if you just stay on top of it.

 

[alreadylernd]

I seroconverted between 1st and 2nd year, don't ask me how, we have such little patient contact during first year. It's 9 months of isoniazid assuming you don't have active disease (your PCP should order a CXR to confirm), QD (I did it QHS to ensure I'd always remember). It kind of sucks since no alcohol during that time. But it's really no big deal. Taking the INH (that's the abbreviation for isoniazid) is a good idea since recent converters are most likely to develop active TB in the first 2 years after conversion.

I was talking with one doc who said by the time you're 50, if you're a health care worker, you'll have a positive skin test. Of course, I was talking with a pulmonolgist in TB clinic this year and he said he's never tested positive...go figure.

 

[CANES2006]

Been exposed to active TB numerous times during third and fourth year. I have not seroconverted as of yet, but it is only a matter of time since we have a high volume of international patients at Miami. I wouldn't freak about it. You're going to be a doctor and you'll inevitably be exposed to infectious diseases. It's part of the package.

 

[chicamedica]

Thanks guys, i feel sooooooooo much better. I also just talked to my mom who, having grown up in russia, was surrounded by tons of TB-infected people, and she never got TB. I dont mind taking the isoniazid. I'll take it, i just dont want TB. 😱

 

[penguins]

I seroconverted after a trip to Indian, clear CXR, given a script for INH x 9months but was told by the nurse who gave it to me that I didn't have to take it. So... I didn't - at the time I didn't understand it all. My CXRs were negative for the first couple years. Now my CXR says I have an old lesion in an upper lobe. This was after about 4 years with no CXR.
Is it too late to take INH? How do I know what the lesion is?
I have never gotten a good answer and my doc didn't even think it needed to be addressed.
Just wondering, since we are on the topic.

 

[inositide]

I seroconverted after a trip to Indian, clear CXR, given a script for INH x 9months but was told by the nurse who gave it to me that I didn't have to take it. So... I didn't - at the time I didn't understand it all. My CXRs were negative for the first couple years. Now my CXR says I have an old lesion in an upper lobe. This was after about 4 years with no CXR.
Is it too late to take INH? How do I know what the lesion is?
I have never gotten a good answer and my doc didn't even think it needed to be addressed.
Just wondering, since we are on the topic.

It depends on what type of lesion it is. Is it a coin lesion? If I were you, I would absolutely see a pulmonologist and have the lesion further characterized either with CXR interpretation by a more experienced radiologist, or by Chest CT, needle biopsy, or bronchoscopy if necessary.

Before medical school, and perhaps even as a pre-clinical student, I used to believe that only older people got lung cancer. However, during my clinical years I have seen people as young as their late 20s presents with Stage 4 lung cancer and it is truly shocking to see. In all likelihood, the lesion you have is nothing serious. However, as I said, if I were you, I would have it further characterized. The other thing of note is that primary pulmonary TB infection generally occurs in the lower lobes, whereas secondary or reactivation pulmonary TB seen is more often seen in the upper lobes.

It is not something to acutely stress about, but strongly consider getting this lesion further interpreted.

 

[alreadylernd]

I seroconverted after a trip to Indian, clear CXR, given a script for INH x 9months but was told by the nurse who gave it to me that I didn't have to take it. So... I didn't - at the time I didn't understand it all. My CXRs were negative for the first couple years. Now my CXR says I have an old lesion in an upper lobe. This was after about 4 years with no CXR.
Is it too late to take INH? How do I know what the lesion is?
I have never gotten a good answer and my doc didn't even think it needed to be addressed.
Just wondering, since we are on the topic.

I'm just a third year, but we spend one day a week in TB clinic on outpatient medicine. Did the CXR say anything more descriptive than "lesion"? I think the next course of action would be to collect sputum samples (x3) and send for culture...I think your PCP might not have the experience with TB and a pulmonologist would have a better handle on it. Depending on active TB or not, other drugs are thrown into the mix including rifampin, ethambutol and one other I can't remember.

 

[alreadylernd]

I'm just a third year, but we spend one day a week in TB clinic on outpatient medicine. Did the CXR say anything more descriptive than "lesion"? I think the next course of action would be to collect sputum samples (x3) and send for culture...I think your PCP might not have the experience with TB and a pulmonologist would have a better handle on it. Depending on active TB or not, other drugs are thrown into the mix including rifampin, ethambutol and one other I can't remember.

I agree with inositide's post. But one thing is that Penguins mentioned he had a positive PPD in years past, therefore, if his current CXR reading were actually TB, it would be reactivation since he had latent TB previously and would correspond to the upper lobe location.

But seriously, it is not something to stress over immediately.

 

[u_r_my_serenity]

Penguins, if you are symptomatic then you really need to start treatment with more than just isoniazid immediately. If you are asymptomatic, given your history of a positve PPD and clear CXR that subsequently showed changes, I would start treatment anyway. Upper lobe is very suspicious for TB, especially if you're young. The problem is that isoniazid may no longer be effective alone if you have a nodule (how big is it?) and you may actually induce resistance if you try that, which will complicate things later. I would get a hold of your old CXR and get a new one; that will be the single best piece of information (see if there are further changes), and I would definitely start some type of treatment before it gets out of hand down the line. I'm not trying to knock anyone, but don't go to family medicine or a nurse; talk to either a pulmonary care or infectious disease doc. When you start treatment you want to be aggressive enough to get the infection on the first try to prevent resistance, which is BAD for mycobacteria.

 

[penguins]

Okay,
I don't have any sputum to give though! I don't have any syptoms and the CXR just said "small old lesion" - I don't remember the measurements but my PCP didn't seem to care. I have thought about following up but I didn't think INH would help at this point. It wasn't indicative of TB because I had asked about it specifically because I was having fever of unknown origin and nausea for a long time and I was getting tested for lots of things. With all my travels, the diff dx was about 3 pages long. Those ID guys gets excited about high sed rates and FUO.
Although who really knows. The report was read to me over the phone.
I am sure when I start residency I will have to get a new CXR just because as a new employee you must have one if you have a positive PPD. I will call tomorrow and see if I can get the report.

 

[southerndoc]

****!! MY PATIENT MAY HAVE ACTIVE TB!!!!!!!!!! I have been around her for like 5 days! 😱 😱 😱

How soon should I get a PPD placed to see if i seroconverted? Am I supposed to take like 10 drugs for 6 months now?

Has anything like this happened to anyone else?

Some ED nurses have 90% conversion rates after 5 years working in the ED in inner city environments.

I converted while in London and went through 6 months of INH treatment.

 

[that dr. jack]

i've had a positive PPD since i was 16, most likely from time in the hospital as a candy striper. i took one month of INH 10 years ago and every single CXR (once a year or so) since then has been normal. you should do the 9 months of INH, but don't freak out too much because it's so common to have an exposure.

 

[caroladybelle]

After 12 years as a nurse, I have been exposed scads of times. And I received BCG, I am PPD positive.

It really was not a problem and all my chest xrays were negative, until I went to Africa for a brief duty. Shortly thereafter, I also sustained a wild animal bite that caused a severe systemic illness, despite prophylaxis. About six monthes later, a random chest xray showed a ground glass lesion. The following CT showed granuloma scarring on the lung, liver and spleen.

I got bronched, and all cultures were negative. But I still had to do 12 monthes of INH. I really didn't have any problems with my LFTs from it.

We still don't know what I picked up that caused the granulomas, or whether it was from the Africa trip or the raccoon bite.

--------------------------------------------------------------------------
One thing for y'all to consider guys, is if you think that your patient might have TB or has significant risk factors...PUT THEM ON RESPIRATORY ISO until ruled out.

There is nothing so likely to tick the nursing/PT/OT/ID departments off than working with the patient hacking and coughing up a lung for two weeks (usually right in our faces) just to have you say, "Well maybe we need to do an AFB"....and it comes up positive.

I have dealt with numerous MDs that did not want to institute resp. iso. because "It upsets the patient" or "It is so inconvenient". A pox (or TB) on their houses.

 

[chicamedica]

Cool, i feel a lot more serene about this exposure now. I really appreciate all the personal experiences everyone has shared. I didn't realize how common this was, in the US anyway. You guys are awesome 😍 . . .SDN rulez.

 

[caroladybelle]

Cool, i feel a lot more serene about this exposure now. I really appreciate all the personal experiences everyone has shared. I didn't realize how common this was, in the US anyway. You guys are awesome 😍 . . .SDN rulez.

In central Florida, it is/was very prevalent.

Large numbers of migrant workers living in close quarters with little health care followup. In Florida, most places will fund the meds to get the poor to take them. Which means that the migrant will (maybe) take the meds for a few weeks, monthes while in the area, harvesting crops. Then they move on to a few more areas, where they cannot get the meds. A year later, they are back in Florida, with RESISTANT TB.

Not to mention, the difficulty getting patients to take TB meds with any consistancy for 6-12 monthes....or do the required blood work.

To add to the problem, there is a larger than average HIV+ population.

At one point in the mid 90s, some hospitals put all HIV+ patients in resp. iso. until ruled out. However, it is my understanding that is no longer the case as HIV disease is being managed better with meds now.

One of my veteran patients literally went to surgery twice (had two chest xrays, also) and no one caught the issue. He was in the hospital for three weeks. Then he gets sent to us, and as soon as he coughes, he gets checked. Not just TB, he had MDR TB.

 

[southerndoc]

Some states (e.g., Connecticut) require that a nurse or healthcare worker witness you taking your medicines at least during weekdays (5/7 days).

When I converted, Georgia paid for all my medicines and laboratory tests (for LFT's), even though I was in a high income bracket. Georgia considers it a public health emergency and pays for everyone's TB meds. There really is no excuse to not be treated for TB in most states.

 

[glorytaker]

Some states (e.g., Connecticut) require that a nurse or healthcare worker witness you taking your medicines at least during weekdays (5/7 days).

When I converted, Georgia paid for all my medicines and laboratory tests (for LFT's), even though I was in a high income bracket. Georgia considers it a public health emergency and pays for everyone's TB meds. There really is no excuse to not be treated for TB in most states.

Wow, and I thought Georgia was a red state.

 

[Bobblehead]

Some states (e.g., Connecticut) require that a nurse or healthcare worker witness you taking your medicines at least during weekdays (5/7 days).

When I converted, Georgia paid for all my medicines and laboratory tests (for LFT's), even though I was in a high income bracket. Georgia considers it a public health emergency and pays for everyone's TB meds. There really is no excuse to not be treated for TB in most states.

DOT (directly observed therapy) is the standard of care for someone with active Tb (i.e. class III pulmonary disease). These are also the people that are started on 4 drug therapy until culture (and sensitivities) come back at which point in time they can be dropped to a more narrow regimen assuming their strain isn't resistant.

For someone that's converted their PPD for whatever reason with a negative CXR they are generally considered class II (LTBI) and recommended for prophylaxis which they may refuse. Prophylaxis is usually 9 months of INH although there are variations on that theme. This is usually done without observation. If someone's considered unreliable it may actually be better to not treat them since their risk of converting is generally fairly low, all other things being equal. Usually Tb treatment is free (visits, tests, X-rays, drugs) because it is a public health hazard if there is someone walking around with active Tb.

 

[gwen]

sorry, didn't read the posts above...too long.

just wanted to drop a line about this...

i know ID attendings who are PPD positive and refuse to take INH. they feel its side effects are worse than the "potential" benefits.

also, i know tons of FMGs who worked in india in TB hospitals, didn't wear a mask, and are doing just fine. they just get a cxr every time they start a new job.

i'm out!

 

[penguins]

sorry, didn't read the posts above...too long.

just wanted to drop a line about this...

i know ID attendings who are PPD positive and refuse to take INH. they feel its side effects are worse than the "potential" benefits.

also, i know tons of FMGs who worked in india in TB hospitals, didn't wear a mask, and are doing just fine. they just get a cxr every time they start a new job.

i'm out!

Gosh, that is good to hear that even ID docs thought that. It still makes me mad though that when I was 20 and the hospital nurse told me when she gave me the INH script how terrible the side effects were and that I didn't have to take it. I didn't know enough to really make an informed choice and she really steered me away from it.
I am sure I got in on a train in India. There were people coughing up blood all around me. Ewww!
Thanks, Gwen. It is hard to know because people are really divided on this. I'll just find out what my lesion is.

 

[southerndoc]

You are right Bobblehead. DOT is for active TB. There is no requirement for PPD converters to get prophylaxed. I was given the option and was told I had a 5% chance of developing TB at some point in my life without the prophylaxis, and a 0.1% chance with. Not sure if these numbers are correct, but I opted for treatment.