In recent years, the decrease in reported tuberculosis in the United States has been due almost entirely to a drop in the number of cases of pulmonary disease. There has been little change in the average number of extrapulmonary cases reported. A retrospective survey of extrapulmonary tuberculosis has shown that it differs from pulmonary tuberculosis with regard to sex and race distribution, diagnosing physician's speciality and proportion of cases bacteriologically confirmed. There is variation within extrapulmonary cases according to specific anatomic site with regard to the above characteristics as well as age distribution. These epidemiologic differences in tuberculosis of different sites are unexplained.

Treatment of Tuberculosis. 1. A 6-mo regimen consisting of isoniazid, rifampin, and pyrazinamide given for 2 mo followed by isoniazid and rifampin for 4 mo is the preferred treatment for patients with fully susceptible organisms who adhere to treatment. Ethambutol (or streptomycin in children too young to be monitored for visual acuity) should be included in the initial regimen until the results of drug susceptibility studies are available, unless there is little possibility of drug resistance (i.e., there is less than 4% primary resistance to isoniazid in the community, and the patient has had no previous treatment with antituberculosis medications, is not from a country with a high prevalence of drug resistance, and has no known exposure to a drug-resistant case). This four-drug, 6-mo regimen is effective even when the infecting organism is resistant to INH. This recommendation applies to both HIV-infected and uninfected persons. However, in the presence of HIV infection it is critically important to assess the clinical and bacteriologic response. If there is evidence of a slow or suboptimal response, therapy should be prolonged as judged on a case by case basis. 2. Alternatively, a 9-mo regimen of isoniazid and rifampin is acceptable for persons who cannot or should not take pyrazinamide. Ethambutol (or streptomycin in children too young to be monitored for visual acuity) should also be included until the results of drug susceptibility studies are available, unless there is little possibility of drug resistance (see Section 1 above). If INH resistance is demonstrated, rifampin and ethambutol should be continued for a minimum of 12 mo. 3. Consideration should be given to treating all patients with directly observed therapy (DOT). 4. Multiple-drug-resistant tuberculosis (i.e., resistance to at least isoniazid and rifampin) presents difficult treatment problems. Treatment must be individualized and based on susceptibility studies. In such cases, consultation with an expert in tuberculosis is recommended. 5. Children should be managed in essentially the same ways as adults using appropriately adjusted doses of the drugs. This document addresses specific important differences between the management of adults and children. 6. Extrapulmonary tuberculosis should be managed according to the principles and with the drug regimens outlined for pulmonary tuberculosis, except for children who have miliary tuberculosis, bone/joint tuberculosis, or tuberculous meningitis who should receive a minimum of 12 mo of therapy.(ABSTRACT TRUNCATED AT 400 WORDS)

No abstract

Francisco, funded by the Centers for Disease Control and Prevention (CDC). The development of the first edition of this Guide was funded through CITC/CDPH Interagency Agreement 03-75851. The second edition was funded through CDC Cooperative Agreement U52 CCU 900454. Permission is granted for nonprofit educational use and library duplication and distribution. Second printing.

An outbreak of tuberculosis in 1976 was caused by mycobacteria resistant to isoniazid (INH), streptomycin (SM), and para-aminosalicylic acid (PAS). High rates of infection associated with exposure to the index case suggested that transmission of resistant organisms had occurred, and the subsequent appearance of bacteriologically proven INH-SM-PAS-resistant tuberculosis in four school contacts of the index case confirmed this fact. Retrospective investigation revealed that the school outbreak was part of an ongoing community outbreak dating back at least to 1964. Through the use of case histories, drug-susceptibility patterns, and phage typing, 15 documented and seven presumed INH-SM-PAS-resistant, epidemiologically linked cases were found; two of these persons died of tuberculosis. Six additional cases with INH-SM-PAS resistance that could not be epidemiologically linked to the outbreak were also identified. The potential of drug-resistant strains for causing disease in humans should not underestimated.