Clinical standards for drug-susceptible TB in children and adolescents

Abstract

BACKGROUND: These clinical standards aim to provide guidance for diagnosis, treatment, and management of drug-susceptible TB in children and adolescents.METHODS: Fifty-two global experts in paediatric TB participated in a Delphi consensus process. After eight rounds of revisions, 51/52 (98%) participants endorsed the final document.RESULTS: Eight standards were identified: Standard 1, Age and developmental stage are critical considerations in the assessment and management of TB; Standard 2, Children and adolescents with symptoms and signs of TB disease should undergo prompt evaluation, and diagnosis and treatment initiation should not depend on microbiological confirmation; Standard 3, Treatment initiation is particularly urgent in children and adolescents with presumptive TB meningitis and disseminated (miliary) TB; Standard 4, Children and adolescents should be treated with an appropriate weight-based regimen; Standard 5, Treating TB infection (TBI) is important to prevent disease; Standard 6, Children and adolescents should receive home-based/community-based treatment support whenever possible; Standard 7, Children, adolescents, and their families should be provided age-appropriate support to optimise engagement in care and clinical outcomes; and Standard 8, Case reporting and contact tracing should be conducted for each child and adolescent.CONCLUSION: These consensus-based clinical standards, which should be adapted to local contexts, will improve the care of children and adolescents affected by TB.

Pediatric Tuberculosis: A Review of Evidence-Based Best Practices for Clinicians and Health Care Providers

“…However, when the clinical diagnosis is uncertain, it is important to recognize that a treatment decision does not always have to be made based on initial presentation. Many children with TB or presumptive TB are not severely unwell, and so a follow-up evaluation in two to three weeks with reassessment of clinical features and weight can be very helpful in treatment decision-making, including to avoid overdiagnosis and treatment [ 18 , 39 ]. Clinical or treatment decision algorithms have been used for decades to integrate available information to inform a decision, regardless of access to bacteriologic confirmation.…”

“…These challenges may hinder the appropriate evaluation of children for TB disease [ 6 , 14 , 15 , 16 ]. Children have difficulty providing high-quality, spontaneously expectorated sputum for diagnostic testing, especially young children, and often require more invasive sampling procedures such as sputum induction or gastric aspiration [ 6 , 14 , 17 , 18 ]. Consequently, increased use of less invasive specimens (e.g., stool, urine, nasopharyngeal aspirates (NPA)) is now recommended.…”

“…However, these specimen types often have fewer mycobacteria, resulting in decreased test sensitivities for young children [ 19 , 20 ]. Clinical diagnosis based on signs, symptoms, patient history, and radiography therefore remains critically important for identifying TB in children [ 18 , 21 ]. Furthermore, clinicians often need to use every piece of information available to guide a clinical decision on TB treatment for pediatric patients with presumed TB but with negative diagnostic test results (see Treatment Decision Algorithms below).…”

“…Once initiated on treatment, children respond well to preventive and curative treatment regimens for drug-susceptible (DS) and drug-resistant (DR) TB, generally experiencing fewer and less severe side effects and better treatment outcomes than adults if treatment completion can be assured [ 6 , 18 , 22 ]. This better response to treatment underscores the opportunities lost due to challenges in TB case-finding for children.…”

Perinatal tuberculosis—An approach to an under-recognized diagnosis

“…Central nervous system (CNS) TB, such as TB meningitis and tuberculomas, should be excluded-lumbar puncture for obtaining CSF for chemistry, cell count, and microbiological testing is important in all young infants presenting with presumed TB (39). Brain CT or magnetic resonance imaging (MRI) scans are important if CNS involvement is considered or if CXR shows miliary TB.…”