Protocol for the diagnosis and management of tuberculosis in adults
Department of Internal Medicine, PMHC
Tuberculosis is a national emergency with probably at least 300,000 cases occurring annually in RSA. Co
infection with HIV is common with around 75% of tuberculosis patients also being HIV infected. The
national department of health has produced excellent comprehensive guidelines on the diagnosis and
management of tuberculosis. These guidelines should be consulted for the protocols for diagnosis and
management of tuberculosis. The latest edition of the guidelines is available on the intranet. The majority
of paients with tuberculosis are diagnosed and managed in the community via the primary health care
clinics. At Ngwelezane the tuberculosis clinic is based at the end of the eye ward and is managed by CPN
Ngozo. The aim of this protocol is to provide guidance and reminders to try to ensure inpatients are
correctly investigated for tuberculosis. It is interesting to note that autopsy series from Africa show that
around 50% of medical patients dying in hospital have undiagnosed tuberculosis. This suggests that we
should have a low index of suspicion for diagnosing tuberculosis.
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All patients admitted with respiratory symptoms such as cough, shortness of breath, haemoptysis
or chest pain should have a sputum examination for acid fast bacilli (AFB).
Patients admitted with lobar pneumonia should also have sputum examined for AFB.
Patients with fever without an obvious cause should be investigated for TB. Check the patient for
lymphnodes – if fluctuant aspirate for AFB (or biopsy), consider ultrasound to look for ascites and
para-aortic nodes. Do a chest x-ray looking for hilar nodes, pleural effusions, evidence of
cavitation etc. Consider cardiac echo if the heart is enlarged. Aspirate any swollen joints, consider
biopsy of any skin lesion that might be related to TB. Take early morning urine if renal TB is
selected. In patients with confusion or headache do a lumber puncture.
In cases of suspected pulmonary TB ensure that sputum is taken for AFB microscopy. Also if the
patient has had previous TB or has been in contact with other TB patients request TB culture with
sensitivity. Make sure you fill the request form correctly include as much contact information as
possible because if the patient turns out to have MDRTB on culture they will need to be traced!!!
If a patient has been started on TB treatment on clinical grounds by the time they are admitted to
the ward still take a sputum sample to prove the diagnosis and to allow culture if indicated.
TB treatment is given as a combination pill to increase compliance. Ensure the patient is weighed
and that they are taking the correct dose of treatment. If the patient was too sick to be weighed
before they started treatment ensure that they are weighed before they go home and treatment dose
is adjusted accordingly.
The different TB treatment regimens and doses are shown in the national treatment guidelines.
Make sure you ask the patient if they have had TB before as the regimen differs for new patients
and retreatment patients.
On discharge TB patients should have a green TB card completed and the patient should be sent to
the TB clinic to be registered.
Other important points
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TB treatment and ARV's. TB treatment interacts with several ARV's. Specifically there is a danger
of liver failure in patients taking nevirapine who are given TB treatment. If you want to start a
patient on TB treatment who is taking ARV's ask advice from Thembalethu clinic or one of the
medical consulatants.
Women taking hormonal contraceptive therapy should have the dosing interval of injectable
contraceptives reduced and the pill free interval on the OCP reduced from 14 to 7 days as
rifampicin reduces the efficacy of hormonal contraceptives.
Patients who become jaundiced whilst taking TB treatment should have their treatment stopped
and should be discussed with one of the medical consultants
Patients found to have MDRTB on culture should be discussed with one of the medical
consultants or discussed with the TB team at King George hospital.