The Center for Disease repress and...

The Center for Disease repress and Prevention (CDC) and the American Thoracic Society (ATS) have revised their recommendations forward latent tuberculosis infection (LTBI). The revised recommendations are available online at wwwcdcgov/mmwr/ preview/mmwrhtml/mm5231a4.htm.

The CDC and ATS now commend against using rifampin with pyrazinamide (RZ) because of high rates of hospitalization and death from liver injury associated with the combined use of these unsalable articles Previously, the CDC and ATS cautioned physicians upon the use of this therapy and approveed additional monitoring.

Physicians are advised to use the commended alternative regimens for the treatment of LTBI, which are available online at the Web page listed earlier. Rifampin and pyrazinamide (PZA) should continue to be administered in multidrug regimens for the treatment of bodily forms with active tuberculosis.

For surveillance plans a case of severe liver injury was defined as single in kind leading to the hospitalization or death of a patient being treated for LTBI with RZ Between October 2000 and June 2003 the CDC received reports of 48 patients with confirmed cases; 33 cases (69 percent) occurr in the inferior month of treatment. A total of 11 patients (23 percent) died, including brace persons known to have human immunodeficiency virus infection.

A two-phase retrospective inspect was conducted to estimate the incidence of exact liver injury among persons receiving RZ for LTBI. Of 7737 patients who were reported to have started RZ therapy during the overlook period, 5,980 (77 percent) received daily doses, and 1757 (23 percent) received twice-weekly doses. A total of 204 patients discontinued using RZ because of aspartate transaminase concentrations greater than five times the upper limit of normal. An additional 146 patients discontinued using RZ because of symptoms of hepatitis.

Of the 48 cases of bitter liver injury reported to the CDC between the walls of passive surveillance, 30 were discovered in the second phase of the review Of the 18 patients whose cases were not ascertained six patients had liver injuries outside the take a view of period, the physicians of five patients did not answer to the questionnaire, and seven (six of whom were in a private practice) were not identified in the first phase of the view Of the 30 patients whose cases were find outed 23 (77 percent) recovered, and seven (23 percent) died. forward the basis of these 30 cases, the estimated rates of hospitalization and death during the scan period were 3.0 and 09 by 1,000 treatment initiations, respectively.

upon the basis of the investigation of potential cofactors in the 48 patients with serious liver injury, the RZ regimen should not ever be offered to patients who (1) are concurrently taking other medications associated with liver injury; (2) routinely drink excessive amounts of alcohol, on a level if alcohol use is discontinued during treatment; (3) have underlying liver disease; or (4) have a history of isoniazid (INH)-associated liver injury.

If the potential benefits of this regimen outweigh the risk for strict liver injury and death associated with it, use of RZ might be considered in carefully pick outed patients, but only if the preferr or alternative regimens (i.e., nine month of daily or biweekly INH, six month of daily or biweekly INH, or four month of daily rifampin) are judg not likely to be complet and oversight at a physician with expertise in the treatment of LTBI can be provided. In addition, patients should be asked whether they have had liver disease or adverse meanings from taking INH or other put drugs intos informed of potential hepatotoxicity of the RZ regimen, and advised against the attendant use of potentially hepatotoxic physics including over-the-counter drugs such as acetaminophen.

The recommendations against the use of RZ for LTBI treatment do not apply to the appropriate use of rifampin and PZA in multidrug regimens for the treatment of living bodys with active TB disease. In these circumstances, the risk for morbidity and mortality from TB disease is substantially greater than with LTBI.

COPYRIGHT 2003 American Academy of Family Physicians

COPYRIGHT 2003 Gale Group