Update on Latent Tuberculosis Infection



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Am Fam Physician. 2014 Jun 1;89(11):889-896.

This clinical content conforms to AAFP criteria for continuing medical education (CME). See CME Quiz Questions.

  Patient information: See related handout on tuberculosis, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

Latent tuberculosis infection refers to an asymptomatic, nontransmissible infection with Mycobacterium tuberculosis, carrying a 5% to 10% lifetime risk of progressing to active disease. One-half of this risk occurs within the first two years after infection. High-risk groups include recent immigrants from high-incidence countries, health care professionals, persons living or working in institutional settings, and homeless persons. Risk factors for progression to active disease include immunodeficiency, recent exposure to tuberculosis, and chronic kidney disease requiring dialysis. Tuberculin skin testing has several limitations, including the need for multiple office visits and the potential for false-positive results in patients who have received the bacillus Calmette-Guérin vaccine or been exposed to environmental mycobacteria. Interferon-gamma release assays address these deficiencies but are limited by their cost and requirement for blood processing. Interferon-gamma release assays are preferred in immigrants exposed to bacillus Calmette-Guérin and in patients who are not likely to return for interpretation of skin test results. Tuberculin skin testing is preferred for children younger than five years. Active disease should be excluded before initiating treatment. The newest treatment option of 12 weekly doses of isoniazid and rifapentine has similar or better effectiveness than standard nine-month therapy with daily isoniazid. A four-month regimen of daily rifampin is another alternative.

Infection with Mycobacterium tuberculosis is transmitted by airborne droplets from patients with active respiratory disease.1 After the primary infection, tuberculosis (TB) can progress to active pulmonary disease (most common) or extra-pulmonary disease, or it can remain latent for part or all of the patient's life. About one-third of the world's population is thought to be infected with M. tuberculosis, including an estimated 10 to 15 million latent infections in the United States.2 There is a 5% to 10% lifetime risk of progression from latent TB to active disease.1 One-half of this progression occurs in the first two years after infection, with the remaining risk distributed over the rest of the life span.3  Risk factors for infection and for progression from latent to active disease are listed in Table 1.37 Because more than 80% of active TB cases in the United States arise from latent TB, prompt treatment is key to prevent active disease.3  Patients with latent TB are noninfectious and typically do not feel ill, so the only indication of latent infection is a positive screening test (Table 2).7

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Persons in high-risk populations should be screened for tuberculosis and treated, if necessary.

C

3, 5, 9

Persons in low-risk populations should not be screened for tuberculosis because of the potential for false-positive results. A decision to test is a decision to treat.

C

3, 5

The interferon-gamma release assay is the preferred screening method for tuberculosis in patients with a history of bacillus Calmette-Guérin vaccination and in those unlikely to return for interpretation of tuberculin skin test results. Skin testing is preferred in children younger than five years.

C

9

Twelve weekly doses of isoniazid and rifapentine (Priftin) administered under direct observation are as effective as a nine-month regimen of daily isoniazid, and may result in better patient compliance.

B

34, 35


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

View Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Persons in high-risk populations should be screened for tuberculosis and treated, if necessary.

C

3, 5, 9

Persons in low-risk populations should not be screened for tuberculosis because of the potential for false-positive results. A decision to test is a decision to treat.

C

3, 5

The interferon-gamma release assay is the preferred screening method for tuberculosis in patients with a history of bacillus Calmette-Guérin vaccination and in those unlikely to return for interpretation of tuberculin skin test results. Skin testing is preferred in children younger than five years.

C

9

Twelve weekly doses of isoniazid and rifapentine (Priftin) administered under direct observation are as effective as a nine-month regimen of daily isoniazid, and may result in better patient compliance.

B

34, 35


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented

The Authors

HOLLY HARTMAN-ADAMS, MD, is a clinical faculty member at West Virginia University Robert C. Byrd Health Science Center School of Medicine in Morgantown.

KAREN CLARK, MD, is assistant clinical director of WELL-WVU Student Health at West Virginia University Robert C. Byrd Health Science Center School of Medicine.

GREGORY JUCKETT, MD, MPH, is director of the International Travel Clinic at West Virginia University Robert C. Byrd Health Science Center School of Medicine.

Address correspondence to Holly Hartman-Adams, MD, West Virginia University Robert C. Byrd Health Science Center School of Medicine, P.O. Box 9247, Morgantown, WV 26506 (e-mail: hhartman@hsc.wvu.edu). Reprints are not available from the authors.

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