Tuberculosis in children

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Alejandro Lemor, M.D. [2]

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Screening for Tuberculosis

Symptom-based Screening Approach

Algorithm adapted from Guidance for National Tuberculosis Programmes on the Management of Tuberculosis in Children

Child in close contact with confirmed tuberculosis case

< 5 yrs old

> 5 yrs old

Asymptomatic

Symptomatic

Symptomatic

Asymptomatic

Administer INH 10 mg/kg/d x 6 months

No preventive treatment is recommended.

If the child develops symptoms

If the child develops symptoms

Confirm the diagnosis of TB with: Chest X-ray TST Sputum or gastric aspirates microscopy evaluation and culture

Screening in Children with HIV

Algorithm adapted from Guidance for National Tuberculosis Programmes on the Management of Tuberculosis in Children
IPT: Isoniazid preventive therapy (INH 10 mg/kg/d x 6 months)

Child with HIV and older than 1 year

Does the patient has any of the following symptoms? Weight loss or poor weight gain Cough Fever History of close contact with a TB case

Yes

No

Assess for the diagnosis of TB (TST, chest X-ray, sputum studies) and rule out other diseases

Does the patient has any of the following contraindications for IPT? Active hepatitis Peripheral neuropathy

TB confirmed

TB ruled out, other diagnosis confirmed

Yes

No

Administer 2HRZE/4HR regimen

Give appropriate treatment for the disease and consider IPT

Do not administer IPT

Administer IPT

Diagnosis

• Children must be evaluated with a complete assessment, which includes:

• Meticulous medical history (symptoms and close contacts with TB)
• Physical examination, that should include growth evaluation.
• TST
• Chest X-ray
• Sputum or gastric aspirate studies (microscopy and culture)
• HIV testing

• Bacteriological testing might be difficult among children, but it should be performed whenever possible.

Diagnostic Approach in Children with Suspected Tuberculosis

Treatment

Tuberculosis in Children   ▸  Drug Susceptible TB   ▸  MDR-TB   ▸  XDR-TB

Drug Susceptible TB Regimen Table adapted from WHO 2013 Treatment of Tuberculosis: Guidelines – 4th ed. MDR-TB Regimen Standard Regimen Group 1: First-line oral drugs ▸ Pyrazinamide 20-30 mg/kg (Max: 600 mg) OR ▸ Ethambutol 15-20 mg/kg OR ▸ Rifabutin 5 mg/kg PLUS Group 2: Injectable drugs ▸ Capreomycin 15-30 mg/kg (Max: 1000 mg) OR ▸ Kanamycin 15-30 mg/kg (Max: 1000 mg) OR ▸ Amikacin 15-22.5 mg/kg (Max: 1000 mg) OR ▸ Streptomycin 12-18 mg/kg PLUS Group 3: Fluoroquinolones ▸ Levofloxacin 7.5-10 mg/kg OR ▸ Moxifloxacin 7.5-10 mg/kg OR ▸ Ofloxacin 15-20 mg/kg divided q12h (Max:800 mg) PLUS Group 4:Oral bacteriostatic second-line drugs ▸ Ethionamide 15-20 mg/kg divided q12h (Max: 1000 mg) OR ▸ Protionamide 15-20 mg/kg divided q12h (Max: 1000 mg) OR ▸ Cycloserine 10-20 mg/kg (Max: 1000 mg) OR ▸ Terizidone 10-20 mg/kg (Max: 1000 mg) OR ▸ Para-aminosalicylic acid 150 mg/kg divided q8-12h(Max: 12 000 mg) Table adapted from WHO 2013 Treatment of tuberculosis: guidelines – 4th ed. and Guidance for national tuberculosis programmes on the management of tuberculosis in children XDR-TB Regimen Standard Regimen Group 1: First-line oral drugs ▸ Pyrazinamide 20-30 mg/kg (Max: 600 mg) OR ▸ Ethambutol 15 mg/kg OR ▸ Rifabutin 5 mg/kg PLUS Group 4:Oral bacteriostatic second-line drugs ▸ Ethionamide 15-20 mg/kg (Max: 1000 mg) OR ▸ Protionamide 15-20 mg/kg (Max: 1000 mg) OR ▸ Cycloserine 10-20 mg/kg (Max: 1000 mg) OR ▸ Terizidone 10-20 mg/kg (Max: 1000 mg) OR ▸ Para-aminosalicylic acid 150 mg/kg/d divided q8-12h PLUS Group 5 Use at least 2 of the following: ▸ Clofazimine 50 mg/d AND 300 mg once a month OR ▸ Amoxicillin/clavulanate OR ▸ Linezolid 300-600 mg OR ▸ Imipenem 500mg q6h OR ▸ Clarithromycin 500-1000 mg q12h OR ▸ Thioacetazone 2.5 mg/kg OR ▸ Isoniazid (high-dose) 16–20 mg/kg Table adapted from WHO 2013 Treatment of tuberculosis: guidelines – 4th ed. and WHO Guidance for national tuberculosis programmes on the management of tuberculosis in children