Initial Workup and Treatment for Suspected Tuberculosis

Diagnostic Workup

• The American Thoracic Society recommends collecting three sputum specimens for acid-fast bacilli (AFB) smear microscopy, mycobacterial culture, and drug susceptibility testing for patients with suspected tuberculosis 1, 2, 3
• The Centers for Disease Control and Prevention suggest performing chest radiography to assess disease extent and identify potential complications 3
• The Infectious Diseases Society of America recommends conducting HIV testing for all patients with suspected TB 4, 3
• The American College of Chest Physicians advises obtaining baseline laboratory tests including liver function tests, especially for HIV-infected persons, pregnant women, persons with history of liver disease, and regular alcohol users 3

Treatment Approach

• The American Thoracic Society recommends initiating a four-drug regimen promptly (isoniazid, rifampin, pyrazinamide, and ethambutol) for patients with high suspicion or seriously ill patients 1, 2, 3
• The Centers for Disease Control and Prevention suggest continuing treatment to complete standard course if diagnosis is confirmed by isolation of M. tuberculosis or positive nucleic acid amplification test 1, 3
• The American College of Chest Physicians recommends a 4-month regimen (2 months of four drugs followed by 2 months of isoniazid and rifampin) for culture-negative pulmonary TB 5, 6, 3

Monitoring During Treatment

• The Infectious Diseases Society of America advises performing monthly clinical monitoring, including assessment for symptoms of hepatitis 3
• The American College of Chest Physicians recommends obtaining sputum cultures monthly until cultures become negative 3
• The Centers for Disease Control and Prevention suggest repeating drug-susceptibility tests if sputum specimens remain culture-positive after 3 months or if cultures revert to positive after initial conversion 3

Common Pitfalls and Caveats

• The American Thoracic Society warns against initiating single-drug therapy as this can lead to development of drug resistance 3
• The Infectious Diseases Society of America advises against adding a single drug to a failing regimen as this can lead to resistance to the added drug 3
• The Centers for Disease Control and Prevention recommend reporting each case of TB promptly to the local public health department within 1 week of diagnosis 4