Latent Tuberculosis Infection Treatment Considerations

Populations Where LTBI Treatment Should NOT Be Pursued

The European Respiratory Society recommends against systematic testing and treatment of LTBI in people with diabetes, harmful alcohol use, tobacco smokers, and underweight individuals, provided they do not fall into high-risk categories requiring treatment 1
The Centers for Disease Control and Prevention suggests that diabetic patients without other high-risk factors should not be treated for LTBI 1
The European Respiratory Society advises against treating persons with harmful alcohol use who are not in priority treatment groups for LTBI 1
Tobacco smokers without additional risk factors should not be treated for LTBI, according to the European Respiratory Society 1
Underweight persons who do not meet other high-risk criteria should not receive LTBI treatment, as recommended by the European Respiratory Society 1

The Centers for Disease Control and Prevention recommends that treatment of LTBI should not be started until a diagnosis of TB disease has been excluded by history, medical examination, chest radiography, and when indicated, mycobacteriologic studies 2, 3
If TB disease presence is uncertain due to equivocal chest radiograph, the Centers for Disease Control and Prevention suggests initiating standard multidrug anti-TB therapy instead 3
Active hepatitis is a relative contraindication to isoniazid or pyrazinamide use, according to the Centers for Disease Control and Prevention 2, 4, 5
End-stage liver disease is a relative contraindication to isoniazid or pyrazinamide use, as recommended by the Centers for Disease Control and Prevention 2, 4, 5
A previous history of severe liver injury from anti-TB medications is a relative contraindication to isoniazid or pyrazinamide use, according to the Centers for Disease Control and Prevention 2, 4, 5

For contacts of MDR-TB patients, close clinical observation for at least 2 years is preferred over preventive treatment, due to limited evidence for efficacy and safety of alternative regimens 7
A history of excessive alcohol consumption makes patients poor candidates for LTBI treatment due to increased hepatotoxicity risk, according to the Centers for Disease Control and Prevention 2, 4, 5

Individuals should be asked about symptoms of TB before being tested for LTBI, as recommended by the European Respiratory Society 1
Those with TB symptoms or any radiological abnormality should be investigated further for active TB before any LTBI treatment consideration, according to the European Respiratory Society 1
Chest radiography should be performed when efforts are intended for active TB case finding, as suggested by the European Respiratory Society 1
Any abnormality on chest X-ray requires full evaluation for active disease before LTBI treatment, according to the European Respiratory Society 1

Never initiate LTBI treatment without excluding active TB disease first, which requires symptom screening, chest radiography, and potentially sputum cultures, as recommended by the European Respiratory Society and the Centers for Disease Control and Prevention 1, 2, 3
Do not retreat patients who completed adequate LTBI therapy unless documented new exposure with high likelihood of reinfection occurs, according to the Centers for Disease Control and Prevention 7
Avoid treating low-risk populations where treatment risks exceed benefits, as recommended by the European Respiratory Society 1
Do not use rifampin-pyrazinamide combination for LTBI due to unacceptably high rates of severe liver injury and death, according to the Centers for Disease Control and Prevention 2, 4, 5