Uganda guidelines for the treatment of Tuberculosis

Pulmonary TB Symptoms

Chronic cough >2 weeks (in HIV, cough of ANY duration), fevers especially evening, excessive night sweats, weight loss, chest pain, purulent or blood-stained sputum.

Extrapulmonary TB Symptoms

Lymph node: Localized enlargement. Abdominal: ascites/abdominal pain. Meningitis: headache, altered consciousness. Bone/Joint: swelling/deformity. Pleural/pericardial effusion.

TB Screening and Investigations

All presumed TB patients should be screened. Obtain sputum for Xpert MTB/RIF (recommended diagnostic test and detects Rifampicin resistance). If not available, do Sputum smear microscopy for AAFBs (ZN stain) but send sample for Xpert. ALL TB patients MUST be offered an HIV test.

Sputum Culture and DST

Confirmatory test. Do for: Rifampicin resistance on GeneXpert, patients on 1st line remaining positive at 2 months, patients suspected failing 1st line.

Drug Resistant (DR-TB) Definitions

RR-TB: Rifampicin resistant. MDR-TB: Resistant to Rifampicin + Isoniazid. XDR-TB: MDR-TB + any fluoroquinolone + bedaquiline/linezolid. INH mono-resistant: Resistant to INH only.

Post-TB Lung Disease

Patient successfully treated but has persistent respiratory symptoms. Re-do standard evaluation (GeneXpert/CXR). If negative, do NOT retreat. Give supportive treatment (pulmonary rehabilitation).

Laboratory Monitoring (Pulmonary TB)

End of 2 months: If smear-negative, start continuation. If smear-positive, do GeneXpert to rule out Rifampicin resistance. Month 5: If smear-positive, diagnose Treatment Failure, do GeneXpert/culture, refer if DR-TB. Month 6: If smear-negative, complete treatment (Cured). If smear-positive, diagnose Treatment Failure.

Treatment Outcomes

Cure: Smear-negative in last month AND on at least one previous occasion. Treatment completed: Completed treatment without evidence of failure but missing final smear. Treatment failure: Positive smear at month 5 or later.

First-Line Regimen (Susceptible TB - Pulmonary/Extrapulmonary)

Excluding TB meningitis/Bone TB. Intensive phase: 2RHZE (2 months). Continuation phase: 4RH (4 months). R=Rifampicin, H=Isoniazid, Z=Pyrazinamide, E=Ethambutol. CAUTION: Rifampicin reduces oral contraceptive efficacy (use barrier method).

TB Meningitis and Bone (Osteoarticular) TB

Intensive phase: 2RHZE. Continuation phase: 10RH (Total 12 months).

Alternative 4-Month Regimen (Adults >12 yrs, >40kg, HIV+ CD4>100)

Intensive: 2 HPMZ. Continuation: 2 HPM. (H=Isoniazid, P=Rifapentine, M=Moxifloxacin, Z=Pyrazinamide).

Drug-Resistant TB (MDR/RR-TB)

Patients with Rifampicin resistance MUST be treated with second-line regimens at designated MDR-TB treatment initiation centers in consultation with the national panel. INH mono-resistance: 6(H)REZ-levofloxacin.

Adjunctive Therapy

Vitamin B6 (Pyridoxine) 25 mg/day given concomitantly with Isoniazid to prevent peripheral neuropathy. Prednisolone (1-2 mg/kg, max 60mg/day for 4 weeks then tapered over 2 weeks) for TB meningitis/severe inflammation.

Side Effect Management: GI / Joint Pains

Low appetite/nausea: Give drugs with small meal or before bed. Joint pains (Pyrazinamide): Give analgesic (Ibuprofen or Paracetamol). Orange/red urine (Rifampicin): Reassure patient it is harmless.

Side Effect Management: Hepatitis / Jaundice

Jaundice/liver failure (Isoniazid, Pyrazinamide, Rifampicin): Stop all drugs immediately. Manage supportively. When resolved, re-introduce single drugs at 3-7 days interval, starting from least likely involved.

Clinical Features in Children

Suspect TB in child with fever >2 weeks, cough >2 weeks, poor weight gain for 1 month, or close contact with pulmonary TB case. Reduced playfulness, poor feeding. GeneXpert should be performed whenever possible.

First-Line Regimen (Susceptible TB)

Intensive phase: 2RHZE. Continuation phase: 4RH. (For all forms of TB excluding meningitis and bone TB).

Alternative 4-Month Regimen (Children 2mo-16yr non-severe)

Intensive: 2 HRE(Z). Continuation: 2RH. (H=Isoniazid, R=Rifampicin, E=Ethambutol, Z=Pyrazinamide).

Pediatric Dosing Reference

Isoniazid: 10 mg/kg (range 7-15). Rifampicin: 15 mg/kg (range 10-20). Pyrazinamide: 35 mg/kg (range 30-40). Ethambutol: 20 mg/kg (range 15-25).